Association Between Health Insurance Literacy and Avoidance of Health Care Services Owing to Cost

Impact of health insurance education program on health care professional students: An interventional study

In the complex landscape of health care, the relationship between medical practice and health insurance is increasingly crucial for effective care delivery. This paper emphasises the importance of integrating health insurance education into medical training, focusing on its impact on patient outcomes, health care accessibility, and system sustainability. It posits that health care providers with a comprehensive understanding of health insurance can offer more informed, efficient care by adeptly navigating coverage complexities. The study utilised a pretest-post-test design with a yearlong health insurance education curriculum at Wake Forest University School of Medicine. Student participants from various medical programmes self-assessed their knowledge and comfort across 13 health insurance topics before and after the intervention. The curriculum included workshops and a capstone project, emphasising real-life patient insurance challenges. Results show statistically significant improvements in 13 participants' understanding of health insurance concepts, highlighting the curriculum's effectiveness. The findings advocate for the inclusion of health insurance education in medical curricula. Such knowledge is vital in systems with diverse insurance models, like the United States, where understanding insurance intricacies is key to patient care. The study's limitations, such as a small sample size and reliance on self-reported data, suggest the need for further research with more participants and objective measures. In conclusion, incorporating health insurance education into medical training is essential for preparing health care professionals to navigate insurance complexities, make informed treatment decisions, and guide patients effectively. This approach fosters well-rounded professionals capable of managing both medical and financial aspects of patient care, leading to more equitable and efficient health care delivery. Future research should explore the long-term effects of this education on clinical practice and patient outcomes, particularly its impact on health care costs and patient satisfaction.

Exploring the factors impacting choice and quality of overnight private hospital stays and consumer perspectives on patient reported experience measures (PREMs) in Australia: a qualitative interview study

OBJECTIVES

Patient reported experience measures (PREMs) are tools often utilised in hospitals to support quality improvements and to provide objective feedback on care experiences. Less commonly PREMs can be used to support consumers choices in their hospital care. Little is known about the experience and views of the Australian consumer regarding PREMs nor the considerations these consumers have when they need to make decisions about attending hospital. This study aimed to explore consumer awareness of PREMs, consumer attitudes towards PREMs and the utility of PREMs as a decision-making tool in accessing hospital care.

METHODS

Qualitative study involving semi-structured interviews conducted over the phone. Participants (n = 40) were recruited from across Australia and purposively sampled according to key characteristics: holding private health insurance, > 30-years of age, may have accessed private hospital care in the past year, variety of educational and cultural backgrounds, and if urban or rural residing. Interviews were audio-recorded, transcribed, and analysed thematically.

RESULTS

Four overarching themes and six subthemes were identified from the data. Major findings were that prior awareness of PREMs was limited; however, many had filled in a PREM either for themselves or for someone they cared for following a hospital stay. Most respondents preferred to listen to experience of self or family/friends or the recommendation of their physician when choosing a hospital to attend. Participants appeared to be more interested in the treating clinician than the hospital with this clinician often dictating the hospital or hospital options. If provided choice in hospital, issues of additional costs, timeliness of treatment and location were important factors.

CONCLUSION

While PREMs were considered a possible tool to assist in hospital decision-making process, previous hospital experiences, the doctor and knowing up-front cost are an overriding consideration for consumers when choosing their hospital. Consideration to format and presentation of PREMs data is needed to facilitate understanding and allow meaningful comparisons. Future research could examine the considerations of those consumers who primarily access public healthcare facilities and how to improve the utility of PREMs.

Health insurance literacy among patients receiving outpatient cancer treatment

BACKGROUND

This study examines patients' understanding of health insurance terms and concepts and quantifies health insurance literacy (HIL) levels by key sociodemographic factors.

METHODS

This study included 393 adult patients with cancer (>18 years old) receiving treatment in two ambulatory infusion centers: Mayo Clinic in Phoenix, Arizona and the University of Mississippi Medical Center in Jackson, Mississippi. Respondents' perceptions of their HIL were assessed using the Health Insurance Literacy Measure (HILM), a validated 21-item measure of a consumer's ability to select and use health insurance (HIL self-efficacy). Respondents' knowledge of health insurance concepts (HIL knowledge) was measured using 10 items created by the Kaiser Family Foundation. The number of correct answers was categorized into three levels: 0-4 (low knowledge), 5-6 (moderate knowledge), and 7-10 (high knowledge). Multivariable logistic regressions were used to compare correct answers to HIL knowledge questions by HIL self-efficacy.

RESULTS

Nearly three-quarters of patients had high HIL self-efficacy and high HIL knowledge (70.5%), understanding basic insurance terms, such as premiums and deductibles. Relatively low percentages of patients correctly answered questions about the meaning of provider networks, health insurance formularies, and calculating out-of-pocket spending in scenarios when insurers pay a portion of allowed charges. Lower HIL knowledge was more common among patients with less educational attainment (

CONCLUSIONS

Efforts to improve HIL and navigation of health insurance plan features are required, especially for socioeconomically vulnerable patients.

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Key Words

• cancer
• cancer disparity
• health inequities
• health insurance
• health insurance literacy
• neoplasms

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MESH Headings Collapse

Grants

• Henry J. Predolin Foundation, Mayo Clinic

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Affiliation(s)

Jingxuan Zhao Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia, USA
Nan Zhang Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, Arizona, USA
Talal Hilal Division of Hematology/Oncology, University of Mississippi Medical Center, Jackson, Mississippi, USA
Joan M Griffin Mayo Clinic, Rochester, Minnesota, USA
K Robin Yabroff Surveillance and Health Equity Science Department, American Cancer Society, Atlanta, Georgia, USA
Nandita Khera Department of Internal Medicine, Mayo Clinic, Phoenix, Arizona, USA

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Health Insurance Navigation Tools Intervention: A Pilot Trial Within the Childhood Cancer Survivor Study

PURPOSE

Childhood cancer survivors are at increased risk for underinsurance and health insurance-related financial burden. Interventions targeting health insurance literacy (HIL) to improve the ability to understand and use health insurance are needed.

METHODS

We codeveloped a four-session health insurance navigation tools (HINT) intervention, delivered synchronously by a patient navigator, and a corresponding booklet. We conducted a randomized pilot trial with survivors from the Childhood Cancer Survivor Study comparing HINT with enhanced usual care (EUC; booklet). We assessed feasibility, acceptability, and preliminary efficacy (HIL, primary outcome; knowledge and confidence with health insurance terms and activity) on a 5-month survey and exit interviews.

RESULTS

Among 231 invited, 82 (32.5%) survivors enrolled (53.7% female; median age 39 years, 75.6% had employer-sponsored insurance). Baseline HIL scores were low (mean = 28.5; 16-64; lower scores better); many lacked knowledge of Affordable Care Act (ACA) provisions. 80.5% completed four HINT sessions, and 93.9% completed the follow-up survey. Participants rated HINT's helpfulness a mean of 8.9 (0-10). Exit interviews confirmed HINT's acceptability, specifically its virtual and personalized delivery and helpfulness in building confidence in understanding one's coverage. Compared with EUC, HINT significantly improved HIL (effect size = 0.94. P < .001), ACA provisions knowledge (effect size = 0.73, P = .003), psychological financial hardship (effect size = 0.64, P < .006), and health insurance satisfaction (effect size = 0.55, P = .03).

CONCLUSION

Results support the feasibility and acceptability of a virtual health insurance navigation program targeted for childhood survivors to improve HIL. Randomized trials to assess the efficacy and sustainability of health insurance navigation on HIL and financial burden are needed.

Bridging the gap: Experimental evidence on information provision and health insurance choices

Previous research has shown that individuals do not always make rational decisions when selecting their health insurance, for example, due to the existence of information frictions or mental gaps. We study the effect of specific types of information provision for decision support on health plan choices and test their potential to improve decision quality by implementing a randomized laboratory experiment. We provide personalized and generic aids, differentiate between numerical and visual decision support, and provide one or two optional formats of personalized information. We find that generic aids have no effect on health plan choices while personalized information leads to better choices as measured by several indicators of decision quality. The largest effects were observed for those who "opted in" to visualize personalized information, with immediate and lasting improvements in health insurance decisions. By reducing information frictions, our results suggest that accessible and easy-to-use tools can positively impact health insurance navigation, improve decision-making, and reduce switching costs.

Evaluating a novel online behavioural intervention to encourage cost-conscious strategies among US adults with chronic conditions who are enrolled in a high-deductible health plan: a proof-of-concept pilot study

OBJECTIVES

Patients with chronic conditions enrolled in high-deductible health plans (HDHPs) face cost-related access barriers and high out-of-pocket spending. Our objectives were to develop a novel behavioural intervention to help HDHP enrollees with chronic conditions use cost-conscious strategies and evaluate the intervention's preliminary effectiveness, acceptability and feasibility.

DESIGN

Prospective.

SETTING

Online (USA).

PARTICIPANTS

36 US adults enrolled in an HDHP through their employer or an exchange with diabetes, hypertension, asthma, coronary artery disease and/or chronic obstructive pulmonary disease. 31/36 participants completed the study.

INTERVENTION

We developed a 5-week intervention consisting of a website with educational modules on discussing costs with clinicians, saving for future healthcare costs, comparing healthcare prices and quality, preparing for appointments, following up after appointments and planning for future healthcare needs; and emails encouraging participants to access each module.

OUTCOMES

We conducted a single-arm proof-of-concept pilot study of the intervention. Baseline and postintervention surveys measured primary outcomes of health insurance literacy and confidence in using cost-conscious strategies. 10 participants completed postintervention interviews.

RESULTS

31 (86%) participants completed a baseline and postintervention survey. Mean health insurance literacy scores (20-80 scale) improved from 56.5 to 67.1 (p<0.001). Mean confidence scores (0-10 scale) improved for talking to a healthcare provider about cost (6.1-7.6, p=0.0094), saving for healthcare (5.8-6.6, p=0.068), comparing prices (5.4-6.9, p=0.005) and comparing quality (6.1 to 7.6, p=0.0034). Participants found the website easy to use and helpful for learning about cost-conscious strategies on postintervention interviews.

CONCLUSIONS

Our novel behavioural intervention was acceptable to HDHP enrollees with chronic conditions, feasible to deliver and associated with increased health insurance literacy and confidence in using cost-conscious strategies. This intervention should be tested in a definitive randomised controlled trial that is fully powered to evaluate its effects on cost-related access barriers, out-of-pocket spending and health outcomes in this growing patient population.

Assessing health insurance literacy in Switzerland: first results from a measurement tool

BACKGROUND

Health insurance literacy (HIL) is crucial for individuals to make informed-decisions and navigate complex choice-based health insurance systems. However, there is a lack of evidence on HIL in countries outside the US, with Switzerland no exception.

METHODS

Using the HILM-CH, a survey instrument developed to measure HIL in Switzerland, this study first describes the answers to the HILM-CH. Second, the study uses ordinary least squares and quantile regressions to investigate the associations between the HIL score and demographic, socioeconomic, health, and preference factors in the German, French, and Italian Swiss regions.

RESULTS

A third of the population faces difficulties in finding health insurance information. Understanding it and managing the financial aspects of the Swiss health insurance system pose the biggest barriers to the population. The HIL score significantly and positively correlates with age and financial risk, while non-Swiss individuals have lower HIL scores. No association was found between HIL, gender, education and time preference. There is a small health gradient, with more doctor visits associated with higher HIL in the lowest quantiles of the HIL score. Similarly, wealthier individuals in the Swiss German part of Switzerland have a higher HIL when choosing their health insurance.

CONCLUSION

This study provides important insights into Swiss HIL and its associated factors. These findings contribute to the international literature on HIL and highlight the importance of understanding variations in HIL and various factors in choice-based health insurance systems.

Unmet need for medical care among Medicare beneficiaries by health insurance literacy and disability

BACKGROUND

Navigating the US healthcare system requires considerable health insurance literacy, especially for adults with disabilities. Limited health insurance literacy may lead to suboptimal treatment, leading to unmet need for medical care.

OBJECTIVE

We examined whether unmet need for medical care among Medicare beneficiaries differs by health insurance literacy and disability status.

METHODS

Using data from the 2010-2019 Medicare Current Beneficiary Survey, we identified 48,989 Medicare beneficiaries, including those in traditional Medicare and Medicare Advantage. Our outcomes were three measures of unmet need for medical care. Our key independent variables were health insurance literacy and disability status. For each outcome, we estimated the adjusted rates of reporting unmet need for medical care by health insurance literacy and disability while controlling for individual-level characteristics.

RESULTS

Unmet need for medical care was higher among Medicare beneficiaries with disabilities across all outcomes, but the highest rates were among those with disabilities and limited health insurance literacy (27.4% [95% CI: 24.9-29.9] for experiencing delayed care, 17.7% [95% CI: 15.6-19.9] for experiencing trouble in getting needed care, and 20.8% [95% CI: 18.5-23.1] for not seeing a doctor despite medical need). Notably, there was an increasing trend in experiencing delayed care and trouble getting needed care among Medicare beneficiaries with disabilities over time, especially for those with limited health insurance literacy.

CONCLUSIONS

Medicare beneficiaries with disabilities and limited health insurance literacy face disproportionate unmet need for medical care. Policies are needed to ensure that these beneficiaries have access to clear and accessible health insurance information.

Cost: An Important Question That Must Be Asked

Cost conversations are essential to informed consent because patients have a right to information that they think is relevant, and patients overwhelmingly report that cost information is relevant to their medical decisions. Providers have an ethical responsibility to provide necessary information for informed consent, and therefore must discuss costs. The Shared Decision Making model is ideal for enabling this exchange of information, and decision aids are also helpful. Although barriers exist, many useful tools can help providers fulfill this obligation, and encouraging progress is being made to improve cost transparency from insurers and facilities.

Black Queer Being/Knowing/Feeling: Storytelling of Barriers to Reproductive Healthcare

Anti-Blackness and heteronormativity are the driving forces that determine access to reproductive healthcare and services in the United States, and the rate of Black birthing-related deaths continue to skyrocket. Still, there is a dearth of literature that includes the reproductive experiences of Black birthing people and their interactions with the healthcare system. This current study builds power with 10 Black Queer birthing people (or Partners) by centering on their gestation-based storytelling within discourse about reproduction. By blending these Partners' self-examination of their lived experiences with gestation with health research, Black feminism, and researcher interpretation of their stories, this study reveals the unparalleled truths of Black Queer reproduction. Six thematic areas within the healthcare system as experienced by Partners are explored. Additionally, through this disruptive approach, this study identifies the lived and material needs that necessitate reproductive justice for all.

Public Health Insurance Status and Utilization of Healthcare Services Across India: A Narrative Review

Health insurance literacy gauges how knowledgeable people are regarding the comparison of health insurance plans to find out the optimal health plan that suits their needs and preferences. Enrolling in a comprehensive plan and proactively addressing health and financial aspects can fortify the stability of families. The plan needs to be used effectively by adapting to evolving circumstances and prioritizing the well-being and prosperity of the household. Having public health insurance can significantly impact an individual's utilization of healthcare services. Having health insurance encourages individuals to promptly seek medical attention without hesitating or avoiding treatment due to financial worries. This results in higher utilization of healthcare services, encompassing routine check-ups, preventive care, and timely intervention for illnesses and injuries. Public health insurance can also improve access to specialized care and expensive treatments that may otherwise be unaffordable for individuals without insurance. By having health insurance, individuals and families can experience a decrease in the economic strain associated with healthcare expenses, thereby enhancing the accessibility and affordability of healthcare services.

Education and Financial Knowledge in Health-Related Financial Decisions

The high cost of health care in the United States creates complex decisions where suboptimal choices may negatively affect an individual's physical and financial health. The challenge for patients is that the complex nature of health-related financial decisions requires specialized knowledge to avoid these suboptimal choices. While the benefits of improved health literacy are well documented, the connection between health care and household finances may mean that there is a role for education and financial knowledge in improving outcomes. This study uses data from the Financial Industry Regulatory Authority's Financial Capability Survey in a binomial logistic regression to examine the role of education and financial knowledge in health-related financial decisions. The results show that both higher levels of education and financial knowledge are related to a higher likelihood of obtaining health insurance coverage and a lower likelihood of having medical debt and engaging in cost avoidance. Income disparities remain, however, especially for those in the middle-income brackets. These results raise the possibility that increases in general education and financial knowledge may improve health outcomes, but those facing the most complex health care decisions may need more specialized knowledge. This implies that given the connection between health care and personal finances, increasing objective and subjective knowledge may lead to better outcomes for patients' financial and physical health.

Health Insurance Literacy Improvements Among Recently Diagnosed Adolescents and Young Adults With Cancer: Results From a Pilot Randomized Controlled Trial

PURPOSE

Adolescents and young adults (AYAs; age 18-39 years) with cancer report needing support with health insurance. We conducted a pilot randomized controlled trial to assess the feasibility and acceptability of a virtual health insurance navigation intervention (HIAYA CHAT) to improve health insurance literacy (HIL), awareness of Affordable Care Act (ACA) protections, financial toxicity, and stress.

MATERIALS AND METHODS

HIAYA CHAT is a four-session navigator delivered program; it includes psychoeducation on insurance, navigating one's plan, insurance-related laws, and managing costs. Participants were eligible if they could access an internet-capable device, were <1 year from diagnosis, and received treatment from University of Utah Healthcare or Intermountain Health systems. We assessed the feasibility, acceptability, and preliminary efficacy of HIAYA CHAT compared with usual navigation care, including HIL (nine items), insurance knowledge (13 items), ACA protections (eight items), COmprehensive Score for financial Toxicity (COST; 11 items), and Perceived Stress Scale (PSS; four items), using t tests and Cohen's d.

RESULTS

From November 2020 to December 2021, N = 86 AYAs enrolled (44.6% participation) and 89.3% completed the 5-month follow-up survey; 68.6% were female, 72.1% were White, 23.3% were Hispanic, 65.1% were age 26-39 years, and 87.2% were privately insured. Of intervention participants (n = 45), 67.4% completed all four sessions; among an exit interview subset (n = 10), all endorsed the program (100%). At follow-up, compared with usual navigation care, intervention participants had greater improvements in HIL, insurance and ACA protections knowledge, and PSS; effect sizes ranged from moderate to large (0.42-0.77). COST did not differ.

CONCLUSION

The results support the feasibility and acceptability of HIAYA CHAT with related improvements in HIL.

Online survey of consumer awareness and perceptions of a Massachusetts law for 12-month supply of contraception

OBJECTIVES

This study aimed to characterize awareness of a 2017 Massachusetts (MA) law that ensures access to a 12-month supply of short-acting contraceptive methods (e.g., pill, patch, and vaginal ring) among short-acting contraceptive users in MA and to identify perceived benefits and concerns of a 12-month supply.

STUDY DESIGN

An online survey was administered to a Qualtrics panel of MA women who were using short-acting contraceptive methods and were insured by an eligible health plan. The survey's primary outcome was general awareness of the law; interest in, receipt of, and perceived benefits and risks of a 12-month supply were also elicited. Analysis included descriptive statistics and bivariate and multivariable analyses examining factors associated with awareness of the law.

RESULTS

Among the 207 survey respondents, 76% were aware of the law, and 93% expressed interest in receiving a 12-month supply of a short-acting method; however, only 9% received it. Respondents identified as White (66%), privately insured (59%), and pill users (44%). Concerns about a 12-month supply included privacy, product expiration, and change in personal medical status. Perceived benefits included avoiding multiple trips to pharmacy and increased compliance. Multivariable analyses showed general awareness of the law was only associated with employer-based insurance, with those respondents having 75% lower odds of being aware of the law than respondents with Medicaid coverage.

CONCLUSION

Although a high percentage of women surveyed were aware of the law and most were interested in receiving a 12-month supply of their short-acting method, the low percentage who have received a 12-month supply suggests barriers to policy uptake.

IMPLICATIONS

This study describes perceptions of the 12-month supply provision of the contraception Act Advancing Contraceptive Coverage and Economic Security in our State law. Addressing consumer concerns may be important to improve the implementation and dissemination of this state policy change.

The Effects of High Deductible Health Plans on Breast Cancer Treatment and Reconstruction

BACKGROUND

High-deductible health plans (HDHP) have expanded rapidly creating the potential for substantially increased out-of-pocket (OOP) costs. The associated financial strain has been associated with the decision to forego care, but the impact on patients undergoing breast cancer reconstruction is not known. We examined the impact of HDHPs vs. LDHPs and OOP maximums on breast reconstruction.

METHODS

Between January 2014 and 2020, patients who had breast reconstruction by the 2 senior authors were retrospectively evaluated. Information on patient's insurance contract was collected. Criteria for HDHP and LDHP were defined following section 223(c)(2)(A) of the Internal Revenue Code. All aspects of cancer diagnosis, cancer treatment, and surgical procedures were reviewed.

RESULTS

About 507 patients (262 in LDHPs and 245 in HDHPs) were reviewed. Patients treated with neoadjuvant chemotherapy were more likely to be enrolled in HDHPs (25.7% vs. 36.8%, P < .01). There was no significant difference in total operations, number of revisions, or length of reconstruction in days or calendar years. Additionally, no difference existed in the choice of autologous implant reconstruction.

CONCLUSION

The cost-sharing burden of HDHPs creates the potential for patients to forego care, and thus, effort should be directed toward increasing patient education concerning health plan benefits. Utilization of postdeductible spending, as well as resources of health savings accounts, may limit the adverse effects of HDHPs. This study also emphasizes the importance for providers to increase cost transparency.

Predictors of Medical Care Delay or Avoidance Among Chinese Adults During the COVID-19 Pandemic

Purpose

Medical care delay or avoidance increases morbidity and mortality risk and is costly for the national healthcare system. The objective of this study was to identify factors associated with medical care delay or avoidance among Chinese adults during the COVID-19 pandemic.

Materials and Methods

A cross-sectional analysis was conducted using data from the 2020 China Family Panel Study (CFPS). The CFPS was conducted from July to December 2020 during the COVID-19 pandemic. The final sample included 4369 adults. A logistic regression model was employed to identify the factors associated with medical care delay or avoidance.

Results

The empirical results indicate that regardless of rural-urban residence, older adults and adults with chronic conditions were less likely to delay or avoid medical care during the pandemic. However, individuals who had completed more than three years of college showed a higher likelihood of delaying or avoiding medical care. In urban areas, larger family sizes, greater general trust in physicians, and higher provider structural quality were associated with a decreased probability of delaying or avoiding medical care during the pandemic. In contrast, employed adults were more likely to delay or avoid medical care. In rural areas, current smokers were more likely to delay or avoid medical care during the pandemic.

Conclusion

This study has identified several factors affecting medical care delay or avoidance, some of which are amenable to policy changes. Policymakers can help improve the utilization of health facilities and patient health outcomes by implementing a series of reforms.

Beyond Being Insured: Insurance Coverage Denial as a Major Barrier to Accessing Care During Pregnancy and Postpartum

This study investigates the association between insurance coverage denial and delays in care during pregnancy and postpartum. An online survey was administered in March and April 2022 to women who were either pregnant or within 1 year postpartum (n = 1,113). The outcome was delayed care, measured at four time points: during pregnancy and 1 week, 2 to 6 weeks, and after 7 weeks postpartum. The key covariate was insurance coverage denial by providers during pregnancy. Delayed care due to having an unaccepted insurance and being "out-of-network" was more pronounced at 1 week postpartum with 3.37 times and 3.47 times greater odds and in 2 to 6 weeks postpartum with 5.74 times and 2.97 times greater odds, respectively. The association between insurance denial and delays in care encapsulated transportation, rural residency, time issues, and financial constraints. The findings suggest that coverage denial is associated with significant delays in care, providing practical implications for effective perinatal care.

Administrative Burden Associated with Cost-Related Delays in Care in U.S. Cancer Patients

BACKGROUND

U.S. cancer patients engage in administrative tasks to pay for their healthcare. This study investigated the relationship between payment tasks and timely access to cancer care.

METHODS

We analyzed online survey data from 510 U.S. cancer patients and survivors to understand the relationship between administrative payment tasks and cost-related delays and nonadherence. Two-part modelling was used to determine if, and to what extent, there was a relationship between administrative burden and cost-related delays/nonadherence.

RESULTS

Younger patients (≤44 years) reported more payment tasks and cost-related delays/nonadherence than older patients (≥ 55 years); African American patients reported more payment tasks and cost-related delays/nonadherence than white patients. After accounting for age, race/ethnicity, education, and out-of-pocket costs, patients who reported engaging in more tasks had greater log odds of delaying/forgoing care [b = 0.18; 95% confidence interval (CI), 0.12-0.24]. Cost-related delays/nonadherence increased by 32% for every unit increase in administrative payment burden (b = 0.32; 95% CI, 0.18-0.46).

CONCLUSIONS

Administrative payment burden increased the odds of cost-related delays and nonadherence by 49%, taking the form of delayed or skipped doctor appointments, tests and bloodwork, and prescription fulfillment. Younger patients and those identifying as African American were more likely to engage in payment tasks and to delay or forgo care due to cost. Administrative burdens can disrupt access to care and traditionally underserved patient populations are disproportionately exposed to these hardships.

IMPACT

Reducing the complexity of healthcare through universal, human-centered design could reduce burdens and increase access.

Association Between Sociodemographic Factors and Vision Difficulty in the National Health Interview Survey: A Population-Based Analysis

PURPOSE

To investigate the relationship between social determinants of health with self-reported vision difficulty.

DESIGN

Cross-sectional, population-based analysis.

METHODS

The National Health Interview Survey (NHIS) is an annual survey based on the U.S. population ≥18 years of age. It provides self-reported data on demographic characteristics, socioeconomic factors, health status, and health care access. The 2021 NHIS database was used in this study. Adult participants of the NHIS who responded to the vision difficulty question "Do you have difficulty seeing, even when wearing glasses or contact lenses?" were included in this analysis. The outcome of interest was self-reported vision difficulty by participants. Analysis was done through univariable and multivariable logistic regression.

RESULTS

Overall, there were 29,464 participants included in the analysis. Univariable logistic regression showed an increased odds of self-reported vision difficulty among female (odds ratio [OR] 1.28 [95% confidence interval {CI} 1.20-1.38]; P < .001), gay, lesbian, or bisexual participants (OR 1.24 [95% CI 1.04-1.49]; P = .02), those who possessed public compared with private insurance (OR 1.83 [95% CI 1.69-1.99]; P < .001), those with less than a high school education (OR 1.88 [95% CI 1.67-2.13]; P < .001), and those with an income below the poverty threshold (OR 2.22 [95% CI 1.96-2.51]; P < .001). Multivariable analysis revealed an increased risk of vision difficulty reported amongst non-Hispanic Black participants (OR 1.65 [95% CI 1.21-2.25]; P = .002).

CONCLUSIONS

A multitude of sociodemographic factors are associated with self-reported vision difficulty in the U.S.

POPULATION

Our findings emphasize the importance of considering factors of social determinants of health in clinical practice and policymaking for patients with vision loss.

Health Insurance Literacy and Medical Care Avoidance Among International Students: A Case Study

Objectives: This research examines the health insurance literacy and healthcare utilization of international students attending a university in the US Midwest. Methods: One hundred and forty-three undergraduate and graduate students attending a midsize metropolitan university in the Midwest completed an online survey in early 2022. Results: Many students surveyed could not identify the definitions of basic terms, such as copay. Furthermore, about 80% of students surveyed could not determine their financial responsibilities in two medical settings. Regression results show that the continent they are from and the length of their stay in the United States significantly predict their understanding of key health insurance terms. More than half of the international students surveyed indicated they often feel confused about their health insurance (57.34%). Only about 20% have delayed or skipped care due to unfamiliarity with the health insurance system. Conclusion: The health insurance literacy of most international students at the midwestern university we surveyed is not ideal. This and possibly other universities in the United States should take more initiatives to help their international students understand the health insurance system.

Health Care Use, Coverage, and Experiences During the Year Prior to Pregnancy in a Primarily Hispanic Population with Low Income: A Descriptive Qualitative Study

INTRODUCTION

A qualitative picture of the health care experiences prior to pregnancy can inform patient-centered strategies to optimize preconception health. This study describes health care utilization and experiences and how health care costs were covered in the year prior to pregnancy in a population of primarily Hispanic women with low income.

METHODS

Pregnant participants were recruited from 5 Federally Qualified Health Center clinics. Semistructured interviews included questions about health care in the year prior to pregnancy. Transcripts were analyzed using a thematic approach that integrated deductive and inductive analysis.

RESULTS

Most participants self-identified as Hispanic. Just under half were US citizens. All but one were Medicaid or Children's Health Insurance Program Perinatal coverage insurance during pregnancy and relied on a variety of strategies to cover prepregnancy health care costs. Almost all received health care during the year prior to pregnancy. Fewer than half reported an annual preventive visit. Health care needs that led to care-seeking included a prior pregnancy, chronic depression, contraception, workplace injury, a persistent rash, screening and treatment for sexually transmitted infection, breast pain, stomach pain (leading to gallbladder removal), and kidney infection. The ways in which study participants covered the costs of health care ranged in terms of sources and complexity. Although some participants described stable health care coverage, most reported changes throughout the year as they pieced together various health care coverage programs and out-of-pocket payments. When participants did seek health care prior to their current pregnancy, most described the experience in positive terms and focused on health care provider communication quality. Respect of patient autonomy was highly valued.

DISCUSSION

Women with pregnancy-related health care coverage accessed care for a wide range of health care needs prior to pregnancy. Health care providers may consider strategies to respectfully introduce preconception care into any visit by an individual who could become pregnant.

Exploring health insurance and knowledge of the ovulatory cycle: evidence from Demographic and Health Surveys of 29 countries in Sub-Saharan Africa

BACKGROUND

Unplanned pregnancy continues to be a major public health concern in Sub-Saharan Africa (SSA). Understanding the ovulatory cycle can help women avoid unplanned pregnancy. Though a wide range of factors for ovulatory cycle knowledge in SSA countries has not been well assessed, the influence of health insurance on ovulatory cycle knowledge is largely unknown. As a result, we set out to investigate the relationship between health insurance enrollment and knowledge of the ovulatory cycle among women of childbearing age. This study aims to investigate the relationship between health insurance enrollment and knowledge of the ovulatory cycle among women of childbearing age in sub-Saharan Africa (SSA).

METHODS

Demographic and Health Surveys (DHSs) data from 29 SSA countries were analyzed. The association between health insurance and ovulatory cycle knowledge was investigated using bivariate and multivariate multilevel logistic regression models among 372,692 women of reproductive age (15-49). The findings were presented as adjusted odds ratios (AOR) with 95% confidence intervals (CI). A p-value of 0.05 was considered statistically significant.

RESULTS

The pooled result shows that the prevalence of knowledge of ovulatory cycle in the studied 29 SSA countries was 25.5% (95% CI; 24.4%-26.6%). Findings suggest higher odds of ovulatory cycle knowledge among women covered by health insurance (AOR = 1.27, 95% CI; 1.02-1.57), with higher education (higher-AOR = 2.83, 95% CI; 1.95-4.09), from the richest wealth quintile (richest-AOR = 1.39, 95% CI; 1.04-1.87), and from female headed households (AOR = 1.16, 95% CI; 1.01-1.33) compared to women who had no formal education, were from the poorest wealth quintile and belonged to male headed households, respectively. We found lower odds of ovulatory cycle knowledge among women who had 2-4 parity history (AOR = 0.80, 95% CI; 0.65-0.99) compared to those with history of one parity.

CONCLUSIONS

The findings indicate that the knowledge of the ovulatory cycle is lacking in SSA. Improving health insurance enrollment should be considered to increase ovulatory cycle knowledge as an approach to reduce the region's unplanned pregnancy rate. Strategies for improving opportunities that contribute to women's empowerment and autonomy as well as sexual and reproductive health approaches targeting women who are in poorest quintiles, not formally educated, belonging to male headed households, and having high parity should be considered.

Access to Healthcare and Health Literacy in Croatia: Empirical Investigation

Health literacy is related to different health-related outcomes. However, the nature of the relationship between health literacy and health outcomes is not well understood. One pathway may lead from health literacy to health outcomes by means of access to healthcare. The goal of the current study is to explore the association between health literacy and the particular measure of access to healthcare-unmet medical need-for the first time in Croatia and, to the best of our knowledge, for the first time in the EU context. We use data obtained from face-to-face interviews in a large nationally representative sample of the Croatian population (n = 1000) to estimate the level of health literacy and self-reported access to care and investigate the association between health literacy and self-perceived barriers to access. Our study showed that limited and problematic health literacy is prevalent and associated with higher rates of unmet medical need. Unmet need is largely caused by long waiting lists. It is therefore essential to design health services fitting the needs of those who have limited and/or problematic health literacy as well as enhance health education with the potential of improving the access to care and health outcomes as well as design policies that reduce waiting times.

"It's just not easy to understand": A mixed methods study of health insurance literacy and insurance plan decision-making in cancer survivors

BACKGROUND

Understanding cancer survivors' health insurance decision-making is needed to improve insurance choice, potentially resulting in reduced financial hardship.

METHODS

This explanatory mixed methods study assessed health insurance decision-making in cancer survivors. Health Insurance Literacy Measure (HILM) captured HIL. Quantitative eye-tracking data collected from two simulated health insurance plan choice sets gauged dwell time (seconds), or interest, in benefits. Dwell time differences by HIL were estimated using adjusted linear models. Qualitative interviews explored survivors' insurance decision-making choices.

RESULTS

Cancer survivors (N = 80; 38% breast cancer) had a median age of 43 at diagnosis (IQR 34-52). When comparing traditional and high-deductible health plans, survivors were most interested in drug costs (median dwell time 58 s, IQR 34-109). When comparing health maintenance organization and preferred provider organization plans, survivors were most interested in test/imaging costs (40s, IQR 14-67). Survivors with low versus high HIL had more interest in deductible (β = 19 s, 95% CI 2-38) and hospitalization costs (β = 14 s, 95% CI 1-27) in adjusted models. Survivors with low versus high HIL more often ranked out-of-pocket (OOP) maximums and coinsurance as the most important and confusing benefits, respectively. Interviews (n = 20) revealed survivors felt alone "to do their own research" about insurance choices. OOP maximums were cited as the deciding factor since it is "how much money is going to be taken out of my pocket." Coinsurance was considered "rather than a benefit, it's a hindrance."

CONCLUSION

Interventions to aid in health insurance understanding and choice are needed to optimize plan choice and potentially reduce cancer-related financial hardship.

Clinical Validity of the PROMIS Healthcare Engagement 8-Item Short Form

BACKGROUND

Healthcare engagement is a key measurement target for value-based healthcare, but a reliable and valid patient-reported measure has not yet been widely adopted.

OBJECTIVE

To assess the validity of a newly developed patient-reported measure of healthcare engagement, the 8-item PROMIS Healthcare Engagement (PHE-8a).

DESIGN

Prospective cohort study of the association between healthcare engagement and quality of care over 1 year. We fit mixed effects models of quality indicators as a function of engagement scores, adjusting for age, race/ethnicity, rural residence, and risk scores.

PARTICIPANTS

National stratified random sample of 9552 Veterans receiving Veterans Health Administration care for chronic conditions (hypertension, diabetes) or mental health conditions (depression, post-traumatic stress disorder).

MAIN MEASURES

Patient experience: Consumer Assessment of Health Plans and Systems communication and self-management support composites; no-show rates for primary care and mental health appointments; use of patient portal My HealtheVet; and Healthcare Effectiveness Data and Information Set electronic quality measures: HbA1c poor control, controlling high blood pressure, and hyperlipidemia therapy adherence.

KEY RESULTS

Higher engagement scores were associated with better healthcare quality across all outcomes, with each 5-point increase (1/2 standard deviation) in engagement scores associated with statistically significant and clinically meaningful gains in quality. Across the continuum of low to high engagement scores, we observed a concomitant reduction in primary care no-show rates of 37% and 24% for mental health clinics; an increased likelihood of My HealtheVet use of 15.4%; and a decreased likelihood of poor diabetes control of 44%.

CONCLUSIONS

The PHE-8a is a brief, reliable, and valid patient-reported measure of healthcare engagement. These results confirm previously untested hypotheses that patient engagement can promote healthcare quality.

Psychosocial Difficulties Experienced by MS Patients in their Quality of Life: A Comparative Study of Two Countries

BACKGROUND

MS is deeply impacted by social factors, such as access to health services, support from official and unofficial sources, and social welfare, which are also thought to contribute to the quality of life of MS patients. The purpose of this study is to examine the quality of life and to analyse the psychosocial challenges of MS patients in North Cyprus and Germany.

METHODS

This study was designed with a cross-sectional and comparative research method. The personal information form and the WHO Quality of Life Scale Short Form were used. A total sixty-eight participants joined the study: 35 German patients and 33 Turkish Cypriot patients. Researchers collected the data by face-to-face interviews between December 2021 and March 2022. The majority of MS patients were females average age was 49.48 years old.

RESULTS

In general, the two populations had comparable total sub-dimension scores of quality of life. However, only environment sub-dimension score has significant difference between Germany (x̄ =70.04) and North Cyprus (x̄ =55.87). Perceived opportunities for accessing medication, physiotherapy, and psychological support, as well as the opportunity to receive psychological support after the time of diagnosis were considered greater in the German group compared to the Turkish Cypriot one.

CONCLUSION

Findings from this cross-sectional research demonstrate significant differences in services provided, particularly in the psychosocial domain, between those in Germany and those in Cyprus. Consequently, all parties in both countries (governments, families, health workers, social workers and people with MS) should cooperate to improve social support mechanisms. Moreover, it is needed better access to health services in Northern Cyprus.

Sociodemographic and behavioural risk factors associated with low awareness of diabetes mellitus medication in Indonesia: Findings from the Indonesian Family Life Survey (IFLS-5)

Introduction

Low awareness of the necessity of taking medication is common among patients with diabetes mellitus (DM) due to their lack of understanding of the disease. Therefore, it is essential to determine the underlying risks influencing low awareness to design effective intervention strategies. This study aims to evaluate the association of sociodemographic and behavioural factors with low awareness to take medication among patients with DM in Indonesia.

Method

Retrospective data were obtained from the Indonesian Family Life Survey (IFLS-5), a national cross-sectional population-based survey among respondents with DM aged ≥15 years. DM status was confirmed by HbA1c testing, while sociodemographic and other health-related information was obtained from self-reported data. Gender, age, educational level, marital status, economic status, comorbidity, religiosity, residence and health insurance status were considered sociodemographic, whereas blood glucose monitoring status, sleeping problems, depression status, having a general medical check-up, satisfaction with healthcare needs and happiness status were considered behavioural risk factors. Awareness of DM medication was determined by self-reported responses to the question asked by the surveyor. Logistic regression analysis was used to evaluate the association between sociodemographic and behavioural factors and low awareness of DM medication. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

Result

Most of the 706 respondents were female (58.8%) and aged 55-65 years (28.8%). Most of them showed low awareness of diabetes medication (87.7%). Irregular blood glucose monitoring (OR: 23.61, 95% CI 11.46-48.65; p < 0.001), without any comorbidity (OR: 2.03, 95% CI 1.05-3.90; p = 0.034), never had any general medical check-up (OR: 2.52, 95% CI 1.12-5.36; p = 0.016), 26-35 years of age (OR: 4.96, 95% CI 1.06-23.19; p = 0.042), 36-45 years of age (OR: 5.04, 95% CI 1.17-21.69; p = 0.030) and having no health insurance coverage (OR: 2.08, 95% CI 1.12-3.87; p = 0.021) were significantly associated with low awareness of diabetes medication.

Conclusion

Healthcare professionals should regularly evaluate blood glucose level, perform routine medical check-ups, prioritise patient satisfaction by providing appropriate care, involve patients in decision-making by determining their needs and then tailor an intervention to meet the need for, and improve their awareness of, DM medication.

Assessing the Impact of Military Service on Patient Health Literacy in an Otolaryngology Clinic

OBJECTIVE

To examine the impact of military service on health literacy.

STUDY DESIGN

Prospective, cross-sectional study.

SUBJECTS AND METHODS

The validated Brief Health Literacy Screen (BHLS) with military supplement was administered to sequential adult patients (military and civilian) treated at two outpatient academic military otolaryngology clinics between November and December 2019. Inadequate health literacy, defined by a BHLS score ≤9, was the primary outcome measure. Secondary outcome measures included comparisons of inadequate BHLS scores with patient demographics and history of military service.

RESULTS

Three hundred and eighty-two patients were evaluated during the study period. The median age was 48-57 years, with a majority being male (230, 60.2%), White (264, 69.1%), married (268, 70.2%), and active duty military (303, 79.3%). A minority reported history of PTSD (39, 13%) or traumatic brain injury (29, 9.6%). Overall, very few subjects (10, 2.6%) demonstrated inadequate health literacy. Patients with prior (1.6% vs 6.3%, P < .05) or current (0% vs 5.0%, P < .05) military service had lower rates of inadequate health literary as compared to civilians. Gender, race, marital status, history of PTSD, and history of traumatic brain injury did not significantly impact health literacy. In a multivariate regression model exploring history of military service, age was not predictive of inadequate health literacy.

CONCLUSIONS

Both history of and current military service predict higher health literacy rates for patients treated at military otolaryngology clinics. Widely accessible health care and mandatory health evaluations for service members to maintain deployment readiness may contribute to this finding but warrant additional study.

High Deductible Health Plans and Use of Free Preventive Services Under the Affordable Care Act

The Affordable Care Act aimed to increase use of preventive services by eliminating cost-sharing to consumers. However, patients may be unaware of this benefit or they may not seek preventive services if they anticipate that the cost of potential diagnostic or treatment services will be too high, both more likely among those in high deductible health plans. We used nationally representative private health insurance claims (100% sample of IBM^® MarketScan^®) for the United States from 2006 to 2018, restricting the data to enrollment and claims for non-elderly adults who were enrolled for the full plan year. The cross-sectional sample (185 million person-years) is used to describe trends in preventive service use and costs from 2008 through 2016. The cohort sample (9 million people) focuses on the elimination of cost-sharing for certain high-value preventive services in late 2010, requiring continuous enrollment across 2010 and 2011. We examine whether HDHP enrollment is associated with use of eligible preventive services using semi-parametric difference-in-differences to account for endogenous plan selection. Our preferred model implies that HDHP enrollment was associated with a reduction of the post-ACA change in any use of eligible preventive services by 0.2 percentage points or 12.5%. Cancer screenings were unaffected but HDHP enrollment was associated with smaller increases in wellness visits, immunizations, and screening for chronic conditions and sexually transmitted infections. We also find that the policy was ineffective at reducing out-of-pocket costs for the eligible preventive services, likely due to implementation issues.

Medicare and Medicaid insurance status is associated with increased allogeneic red blood cell transfusion in cardiac surgery patients: 2007-2018

BACKGROUND AND AIM

Allogeneic red blood cell (RBC) transfusion and health insurance status are independently associated with perioperative morbidity. The aim of this study was to evaluate the effect of insurance status on allogeneic and autologous transfusion risk in cardiac surgery patients.

METHODS

We conducted a retrospective observational study of data spanning 2007-2018 from six states from the State Inpatient Databases. Patients were cohorted by medical insurance type. Rates and risk-adjusted odds ratios (aOR) were calculated for allogenic and autologous RBC transfusions. Interactions between insurance and race/ethnicity were assessed.

RESULTS

A total of 710,296 cardiac surgery patients were included. Allogeneic infusions occurred in 34.7% of Medicare patients, 31.9% of Medicaid patients, 24.7% of privately insured patients, and 26.1% of uninsured patients. Autologous rates were 2.3%, 2.5%, 3.4%, and 2.6% for Medicare, Medicaid, privately insured, and uninsured patients, respectively. Medicare and Medicaid patients were more likely to receive allogeneic RBC than privately insured patients (Medicare: aOR: 1.42, 99% confidence interval [CI]: 1.40-1.44, p < .001, Medicaid: aOR: 1.18, 99% CI: 1.14-1.21, p < .001). Nonwhite Medicare patients showed higher odds of allogeneic transfusion compared with White patients with private insurance (Black Medicare: aOR 1.74, 99% CI: 1.65-1.83, p < .001, Hispanic Medicare: aOR 1.92, 99% CI: 1.84-2.00, p < .001).

CONCLUSION

Cardiac surgery patients with Medicare and Medicaid insurance demonstrate increased risk of allogeneic RBC transfusion; nonwhite patient groups are particularly vulnerable. Further research is needed to understand the causes and implications of these disparities, and to help ensure equitable care across patient groups.

"There's so much they don't cover:" Limitations of healthcare coverage for Indigenous women in a non-federally recognized tribe

Access to healthcare is an essential component in addressing health disparities. However, the limitations of insurance coverage, and other barriers in paying for and accessing healthcare have seldom been researched for Indigenous peoples. In addition, state recognized tribes do not have access to the healthcare services provided by the Indian Health Service, and there is a need for research documenting their unique healthcare needs. Qualitative description was used to conduct 31 semi-structured interviews with women from an Indigenous tribe in the Gulf South to understand their experiences in paying for healthcare services. Participants described: (1) Discrimination Based on Perceived Ability to Pay for Healthcare; and (2) Limitations of Healthcare Coverage, with sub-themes (a) Difficulties Understanding Coverage Limitations; (b) Inadequate Coverage; and (c) Limited Choice of Providers. These findings indicate that state-recognized tribal members may need specialized insurance programs, and more comprehensive coverage of healthcare services and medications. Future actions should promote tribal sovereignty and increase access to healthcare resources for state-recognized tribes.

Beyond Contraception: Pharmacist Roles to Support Maternal Health

While contraception prescribing by pharmacists has seen rapid growth in recent years, pharmacist-provided services that can impact maternal health encompass more than just contraception. Each phase of maternal health-preconception, pregnancy, and post-pregnancy-has unique needs, and pharmacists are well equipped to provide services to meet those needs and are more accessible than other healthcare providers. While pharmacist-provided maternal health services may lead to significant savings to the healthcare system, additional research to more fully capture the value of pharmacist-provided maternal health services is needed. Robust implementation of a pharmacist-provided maternal health services program will require partnerships between providers, payers, and pharmacists. Infant and maternal mortality, preterm birth, and unintended pregnancies are significant public health issues, and pharmacists should be seen as a capable workforce who can provide needed maternal health care and serve as a gateway into the healthcare system for those capable of pregnancy.

Health insurance literacy among head and neck cancer patients and their caregivers: A cross-sectional pilot study

Objective

Health insurance literacy interventions may reduce financial burden and its effects on cancer patients and their caregivers. However, little is known about the health insurance literacy levels of head and neck cancer (HNC) patients and their caregivers. We assessed the feasibility of screening for health insurance literacy in a pilot study and described the health insurance literacy levels of HNC patients and their caregivers.

Methods

We administered a survey that assessed demographics and subjective and objective health insurance literacy to HNC patients and their caregivers. Subjective health insurance literacy was measured through the Health Insurance Literacy Measure (score range: 0-84). Objective health insurance literacy was measured through correct answers to a previously developed 10-question knowledge test. Due to a small sample size, inferential statistics were not used; we instead descriptively reported findings.

Results

The pilot included 48 HNC patients and 13 caregivers. About 44.4% of patients and 30.8% of caregivers demonstrated low health insurance literacy (HILM ≤60). On the 10-item knowledge test, patients had an average of 6.8 (SD: 2.3) correct responses and caregivers had 7.8 (SD: 1.1) correct responses. Calculating out-of-pocket costs for out-of-network services was challenging; only 9.5% of patients and 0% of caregivers answered correctly.

Conclusion

Additional outreach strategies may be needed to supplement screening for health insurance literacy. Areas of focus for interventions include improving understanding of how to calculate financial responsibility for health care services and filing an appeal for health insurance claim denial.

Level of Evidence

IV.

Measuring health insurance literacy in the Netherlands - First results of the HILM-NL questionnaire

BACKGROUND

There are several indications that citizens in the Netherlands struggle to make critical, well-considered decisions about which insurance policy best fits their needs and preferences. This can lead to citizens being sub-optimally insured, facing unexpected costs or suffering inadequate coverage. This study aims to examine how health insurance literacy (HIL) is distributed among citizens in the Netherlands; and to find out whether there are certain groups who have more difficulty choosing and using a health insurance policy.

METHODS

We measured health insurance literacy using the HILM-NL questionnaire, the validated Dutch version of the original health insurance literacy measure (HILM). In February 2020, the HILM-NL was sent to 1,500 members of the Nivel Dutch Health Care Consumer Panel. The response rate was 54% (806).

RESULTS

There is a wide variation in HIL among citizens in the Netherlands. The average total HILM-NL score is 55.14 (on a range of 21-84). The level of education and the household net income are significantly related to HIL.

CONCLUSIONS

Citizens who completed less education or earn a lower income are relatively more likely to have difficulty choosing a health insurance policy or using policy benefits to pay for health services once enrolled. It is important to support these vulnerable groups properly in their choice and use of a health insurance policy.

The challenge of ensuring elderly people can access their health insurance entitlements: a mixed methods study on the Republic of Srpska's Protector of Patients' Health Insurance Entitlements

INTRODUCTION

Healthcare utilisation requires knowing one's entitlements and how to access them (navigation) and having access to grievance redressal when entitlements are denied. To ensure citizen access to and use of health insurance entitlements, the Health Insurance Fund established an initiative called the Protector of Patients' Health Insurance Entitlements (PPHIE). PPHIEs are supposed to provide patient navigation and grievance redressal services. This paper explores to what extent this initiative meets its objectives and is used by the elderly in rural areas.

METHODS

This study employed a mixed methods approach. We conducted in-depth interviews with elderly patients in rural areas, PPHIEs, health providers and health insurance managers (N=39), as well as focus groups (N=5) and a household survey (N=715) with elderly rural patients. Qualitative data were analysed using content analysis, and the household survey results were analysed using descriptive statistics.

RESULTS

The majority of elderly patients were not aware of the PPHIE initiative and instead received patient navigation support from their healthcare providers. The PPHIE programme was poorly publicised among the population. Although PPHIEs had a mandate to pursue grievance redressal they rarely did so, and their role in the system was more symbolic than functional.

CONCLUSION

While healthcare providers have (by default) filled the navigation role left by inactive PPHIEs, the grievance redressal role remains unfilled. Information about health insurance entitlements and access to grievance redressal must be provided through visible, accessible and efficient mechanisms that should be continuously monitored and improved.

Health insurance literacy in the Netherlands: The translation and validation of the United States' Health Insurance Literacy Measure (HILM)

An important criterion for the proper functioning of a managed competition healthcare system, such as operates in the Netherlands, is that all citizens can make well-informed decisions regarding their health insurance policy. In order to achieve this, citizens need certain health insurance literacy skills. It is not known how far citizens in the Netherlands have these skills. The aim of this study is to provide a reliable instrument that measures the health insurance literacy of citizens in the Netherlands. It would be based upon an existing instrument developed in the US. We translated the US Health Insurance Literacy Measure (HILM) into Dutch. Furthermore, we established the psychometric properties of the Dutch version (HILM-NL), and we validated the HILM-NL in a general population sample by sending surveys to members of the Nivel Dutch Health Care Consumer Panel (DHCCP) in February and March 2020. The response rates were respectively 54% (n = 806) and 56% (n = 595). No insurmountable difficulties with equivalence were encountered throughout the translation process. The HILM-NL showed an acceptable level of internal consistency, good test-retest reliability, and a good construct validity. The HILM-NL is a reliable instrument for measuring health insurance literacy among citizens in the Netherlands. With this instrument, it is better possible both to assess how these citizens choose and use a health insurance policy, and also the difficulties they face. It enables citizens in the Netherlands to be supported better in making well-informed decisions on health insurance.

Does the diabetes health plan have a differential impact on medication adherence among beneficiaries with fewer financial resources?

BACKGROUND: The Diabetes Health Plan (DHP), a value-based insurance plan that reduces cost sharing, was previously shown to modestly increase employer-level medication adherence. It is unclear how the DHP might impact individuals with different incomes. OBJECTIVE: To examine the impact of the DHP on individual-level medication adherence, by income level. METHODS: This is a retrospective, quasiexperimental study. An employer-level propensity score match was done to identify suitable control employers, followed by individual-level propensity score weighing. These weights were applied to difference-in-difference models examining the effect of the DHP and the effect of income on changes in adherence to metformin, statins, and angiotensin-converting enzymes/angiotensin receptor blockers. The weights were then applied to a differences-in-differences-in-differences model to estimate the differential impact of DHP status on changes in adherence by income group. RESULTS: The study population included 2,065 beneficiaries with DHP and 17,704 matched controls. There were no significant differences in changes to adherence for any medications between beneficiaries enrolled in the DHP vs standard plans. However, adherence to all medications was higher among those with incomes greater than $75,000 (year 1: metformin: +7.3 percentage points; statin +4.3 percentage points; angiotensin-converting enzymes/angiotensin receptor blockers: +6.2 percentage points; P < 0.01) compared with those with incomes less than $50,000. The differences-in-differences-in-differences term examining the impact of income on the DHP effect was not significant for any comparisons. CONCLUSIONS: We did not find significant associations between the DHP and changes in individual-level medication adherence, even for low-income beneficiaries. New strategies to improve consumer engagement may be needed to translate value-based insurance designs into changes in patient behavior. DISCLOSURES: Drs Ettner and Moin received grants from the Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases (Principal Investigator: Carol Mangione). Mr Luchs received support for attending meetings and/or travel (minimal-mileage and hotel on 2 occasions). Mr Chan has an employee benefit to purchase stock for UnitedHealth Group.

How can healthcare organizations improve cost-of-care conversations? A qualitative exploration of clinicians' perspectives

OBJECTIVES

Clinicians increasingly believe they should discuss costs with their patients. We aimed to learn what strategies clinicians, clinic leaders, and health systems can use to facilitate vital cost-of-care conversations.

METHODS

We conducted focus groups and semi-structured interviews with outpatient clinicians at two US academic medical centers. Clinicians recalled previous cost conversations and described strategies that they, their clinic, or their health system could use to facilitate cost conversations. Independent coders recorded, transcribed, and coded focus groups and interviews.

RESULTS

Twenty-six clinicians participated between December 2019 and July 2020: general internists (23%), neurologists (27%), oncologists (15%), and rheumatologists (35%). Clinicians proposed the following strategies: teach clinicians to initiate cost conversations; systematically collect financial distress information; partner with patients to identify costs; provide accurate insurance coverage and/or out-of-pocket cost information via the electronic health record; develop local lists of lowest-cost pharmacies, laboratories, and subspecialists; hire financial counselors; and reduce indirect costs (e.g., parking).

CONCLUSIONS

Despite considerable barriers to discussing, identifying, and reducing patient costs, clinicians described a variety of strategies for improving cost communication in the clinic.

PRACTICE IMPLICATIONS

Health systems and clinic leadership can and should implement these strategies to improve the financial health of the patients they serve.

Association of Health Insurance Literacy With Financial Hardship in Patients With Cancer

IMPORTANCE

Patient-reported financial hardship is an increasing challenge in cancer care delivery. Health insurance literacy and its association with financial hardship in patients with cancer, especially after controlling for financial literacy, have not been well examined.

OBJECTIVE

To examine the prevalence of and factors in the association between health insurance literacy and financial literacy as well as the overall and individual domains of financial hardship and their association with health insurance literacy, both independently and when adjusted for financial literacy, in patients with cancer.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional survey study recruited and enrolled patients from 2 separate ambulatory infusion centers at Mayo Clinic Arizona in Phoenix, Arizona, and the University of Mississippi Medical Center in Jackson, Mississippi. Adult patients aged 18 years or older were enrolled from December 2019 to February 2020 and from August to October 2020 at Mayo Clinic Arizona (n = 299) and from September 2020 through January 2021 at the University of Mississippi Medical Center (n = 105). Survey respondents received a $5 gift card.

EXPOSURES

Surveys included questions about sociodemographic characteristics, health insurance literacy and financial literacy, financial knowledge, and financial hardship and its domains (material hardship, psychological hardship, and behavioral hardship).

MAIN OUTCOMES AND MEASURES

Financial hardship was assessed using the COST-FACIT (Comprehensive Score for Financial Toxicity-Functional Assessment of Chronic Illness Therapy) measure and National Health Interview Survey questions to capture information about the domains of financial hardship. The Health Insurance Literacy Measure is a validated 21-item measure of a consumer's ability to select and use health insurance. Five questions from the National Financial Capability Study assessed financial literacy.

RESULTS

A total of 404 participants were enrolled in the study. Median (IQR) age of the respondents was 63 (54-71) years, and 219 were women (54%), 307 were non-Hispanic White individuals (76%), 153 (38%) had private insurance, and 289 (72%) had solid tumors. Overall financial hardship (denoted by median COST-FACIT score <27 points) was reported by 49% (95% CI, 44%-53%) of the cohort. Prevalence of financial hardship was higher using the National Health Interview Survey questions, with 68% (95% CI, 63%-72%) of respondents reporting at least 1 hardship domain (n = 276). Sixty-six percent (95% CI, 60%-69%) of respondents (n = 265) had a high level of financial literacy. The mean (SD) Health Insurance Literacy Measure score was 64.9 (13.3) points. In multivariable analyses, each 10-point increase in the Health Insurance Literacy Measure score was associated with lower odds of financial hardship (odds ratio, 0.82; 95% CI, 0.68-0.99; P = .04). However, this association was no longer significant after adjusting for financial literacy.

CONCLUSIONS AND RELEVANCE

Results of this study showed that, despite a high level of health insurance literacy and financial literacy, the prevalence of financial hardship was high. Although there were lower odds of financial hardship with increased health insurance literacy, the association was no longer significant when financial literacy was added to the model, suggesting that a high level of financial literacy may help mitigate the adverse outcome of lower health insurance literacy levels in patients with cancer.

Exploring the Impact of Instruction on College Students' Health Insurance Literacy

Student health insurance literacy is an area of limited prior knowledge, and investigations into this topic have the potential to impact students' self-care strategies, self-efficacy, decision-making, and quality of life. The purpose of this study was to examine factors associated with health insurance literacy and knowledge among undergraduate students. In this study, undergraduate students at one mid-Atlantic public university in the United States who did and did not receive instruction on health insurance were surveyed. Students were recruited from a course that offers formal instruction about health insurance and students in a comparison group at the same university were recruited from a general education participant pool. Participants (n = 364) completed an online anonymous survey that included demographics, experience with health insurance, health insurance knowledge, and health insurance literacy self-efficacy. Hierarchical multiple regression results indicated participants in the course who received health insurance instruction scored higher on a measure of health insurance knowledge. Higher levels of health insurance self-efficacy was also associated with receiving instruction related to health insurance. Female gender and higher parental education were associated with a lower self-efficacy. Improving health insurance knowledge and self-efficacy among undergraduates is an important aspect of preparing students for post-graduate life where decisions about health insurance coverage and healthcare utilization will increase. Furthermore, increasing health insurance literacy may contribute to raising standards of health literacy, health care, and health care seeking across communities.

"I thought there would be more I understood": health insurance literacy among adolescent and young adult cancer survivors

BACKGROUND

Health insurance literacy is crucial for navigating the US healthcare system. Low health insurance literacy may be especially concerning for adolescent and young adult (AYA) cancer survivors. To describe AYAs' health insurance literacy, we conducted semi-structured interviews with AYA survivors, on and off of treatment.

METHODS

We interviewed 24 AYA cancer survivors (aged 18-39 years) between November 2019 and March 2020. Interviews were recorded, transcribed, and quality-checked. Using two cycles of structured coding, we explored AYAs' health insurance literacy and examined thematic differences by policy holder status and age.

RESULTS

AYAs were 58.3% female, 79.2% non-Hispanic White, 91.7% heterosexual, and 62.5% receiving cancer treatment. Most participants had employer-sponsored health insurance (87.5%), and 41.7% were their own policy holder. Four themes emerged; in the first theme, most AYAs described beginning their cancer treatment with little to no understanding of their health insurance. This led to the three subsequent themes in which AYAs reported: unclear expectations of what their insurance would cover and their out-of-pocket costs; learning about insurance and costs by trial and error; and how their health insurance literacy negatively impacted their ability to navigate the healthcare system.

CONCLUSIONS

Our findings, while requiring confirmation in larger samples and in other health systems, suggest that the health insurance literacy needed to navigate insurance and cancer care is low among US AYA survivors and may have health and financial implications. As the burden of navigating insurance is often put on patients, health insurance education is an important supportive service for AYA survivors on and off of treatment.

Health Insurance Literacy Perceptions and the Needs of a Working-Class Community

Background:

Despite increases in the number of insured Americans, consumers continue to face barriers in accessing care. Low levels of health insurance literacy (HIL) are associated with suboptimal use of health insurance coverage. There remains a need to further contextualize the relationship between HIL and access to care, especially among insured working-class people.

Objective

This study was conducted to understand the pathways through which HIL affects health care decision-making and access to care in an urban working-class population.

Methods:

Using a qualitative descriptive approach, we conducted five focus groups with 45 adult residents of South Louisville, Kentucky. The questions explored participants' experiences of insurance enrollment, use, and health care system navigation, as well as their perceptions and needs regarding accessing health insurance information. Using inductive thematic analysis, transcripts were open coded independently by team members, a focused coding framework was agreed upon, and emergent themes were identified through constant comparison techniques.

Key Results:

Most participants placed high value on their insurance, considering it the most important benefit employers offer. Despite having adequate HIL, most participants expressed frustration with the amount of time and effort they spent to determine the best insurance plan, obtain covered health services, and settle claims, often with ineffective results. Despite having insurance, cost considerations influenced many participants' decisions to accept certain tests or treatments, in some cases resulting in delayed or foregone care.

Conclusions:

The findings of this qualitative study indicate that obtaining health care is strongly influenced both by the individual context of HIL knowledge, experience, and life circumstances, and by the structural context of the complex, bureaucratic, and costly health care system. Interventions to improve HIL should include practical examples and real-life scenarios, because HIL gained from experiential narratives was the most useful in navigating the health care system.[HLRP: Health Literacy Research and Practice. 2022;6(2):e61–e69.]

Plain Language Summary:

By conducting focus groups with a working-class population, this study contextualizes the pathways through which HIL affects consumers' health care decision-making and access to care. Findings demonstrate that obtaining health care is strongly influenced both by the individual context of HIL knowledge, experience, and life circumstances, and by the structural context of the complex, bureaucratic, and costly health care system.

Frequency and factors associated with foregone and delayed medical care due to COVID-19 among nonelderly US adults from August to December 2020

OBJECTIVES

To estimate the frequency and factors associated with foregone and delayed medical care attributed to the COVID-19 pandemic among nonelderly adults from August to December 2020 in the United States.

METHODS

We used three survey waves from the Urban Institute's Household Pulse Survey (HPS) collected between August 19-31, October 14-26 and December 9-21. The final sample included 155,825 nonelderly (18-64) respondents representing 135,835,598 million individuals in the United States. We used two multivariable logistic regressions to estimate the association between respondents' characteristics and foregone and delayed care.

RESULTS

The frequency of foregone and delayed medical care was 26.9% and 35.9%, respectively. Around 60% of respondents reported difficulties in paying for usual household expenses in the last 7 days. More than half reported several days of mental health issues. The regression results indicated that foregone or delayed care were significantly associated with difficulties in paying usual household expenses (p < 0.001), worse self-reported health status (p < 0.001), increased mental health problems (p < 0.001), Veterans Affairs (p <0.001) or Medicaid (p = 0.003) coverage compared to private healthcare coverage, and older age groups. Individuals who participated in the latter two waves of the survey (October, December) were less likely to report foregone and delayed care compared to those who participated in Wave 1 (August).

CONCLUSION

Overall, the frequency of foregone and delayed medical care remained high from August to December 2020 among nonelderly US adults. Our findings highlight that pandemic-induced access barriers are major drivers of reduced healthcare provision during the second half of the pandemic and highlight the need for policies to support patients in seeking timely care.

Association of Health Insurance Literacy with Health Care Utilization: a Systematic Review

BACKGROUND

Given increasing numbers of people experiencing transitions in health insurance due to declines in employer-sponsored insurance and changes in health policy, the understanding and application of health insurance terms and concepts (health insurance literacy) may be important for navigating use of health care. The study objective was to systematically review evidence on the relationship between health insurance literacy and health care utilization.

METHODS

Medline, SCOPUS, Web of Science, CINAHL, PsychInfo, Cochrane Library, and reference lists of published literature were searched in August 2019. Quantitative, qualitative, and intervention studies that assessed the association of health insurance literacy as the exposure and health care utilization as the outcome were identified, without language or date restrictions. Outcomes were independently assessed by 2-3 reviewers.

RESULTS

Twenty-one studies including a total of 62,416 subjects met inclusion criteria: three interventional trials, two mixed-methods studies, and sixteen cross-sectional studies. Ten of thirteen preventive care studies suggested that higher health insurance literacy was associated with greater utilization of primary care and other preventive services. Eight of nine studies of care avoidance demonstrated that individuals with lower health insurance literacy were more likely to delay or avoid care. A few studies had mixed results regarding the utilization of emergency department, inpatient, and surgical care.

DISCUSSION

The emerging literature in this area suggests that health insurance literacy is an important factor that can enable effective utilization of health care, including primary care and preventive services. However, the literature is limited by a paucity of studies using validated tools that broadly measure health insurance literacy (rather than testing knowledge of specific covered services). Improving health insurance literacy of the general public and increasing plain language communication of health insurance plan features at the point of health care navigation may encourage more effective and cost-conscious utilization.

Barriers and facilitators affecting presentation in women with early versus advanced stage cervical cancer

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Structural and intrapersonal barriers to cervical cancer care persist but differ between early and advanced stage patients.

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Barriers in the early stage group were lack of knowledge, competing priorities, lack of insurance, and embarrassment.

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Barriers in the advanced stage group were lack of knowledge/risk, competing priorities, avoidance, fear of the healthcare system.

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Innovative methods to increase access to care and engagement with the healthcare system are needed.

Background

This study was performed to evaluate the barriers and facilitators associated with patient presentation for early stage (ES) versus advanced stage (AS) cervical cancer (CC).

Methods

A mixed-method approach was used to collect quantitative (i.e., demographics and medical/screening histories) and qualitative data (individual interviews assessing patients’ perceptions regarding their general health, HPV and CC screening, and barriers and facilitators to CC care). Two separate investigators coded the interviews for major themes that occurred with an agreement that 50% or more of the themes would be included.

Results

Twenty-five women agreed to participate in the study with 80% completing the interview. Patients with ES disease were classified as Stage IA1-Stage IB3; patients with Stage IIA-IVB disease were classified with AS disease. Frequent barriers in the ES group were lack of knowledge, competing priorities, feeling healthy, lack of time or health insurance, and being embarrassed/uncomfortable. Frequent barriers in the AS group were lack of knowledge, competing priorities, avoidance/procrastination, fear of the healthcare system or finding something wrong, and lack of perceived risk to CC. Facilitators for ES included understanding the importance of the Pap test, having an abnormal Pap test, and knowing someone with CC. Having abnormal symptoms was the only facilitator for AS patients.

Conclusions

Structural and intrapersonal barriers to CC care persist but differ between ES and AS patients. Multi-level interventions are needed to address the wide array of issues that women highlighted in this study including potential innovative methods to increase access to care and engagement with the healthcare system.