Patient liability, treatment adherence, and treatment persistence associated with state bans of copay accumulator adjustment programs

BACKGROUND

Health insurers have increased the use of copay accumulator adjustment programs (CAAPs) to control costs; however, some states within the United States have banned the use of CAAPs to protect patients from rising out-of-pocket expenses.

OBJECTIVE

To assess the impact of state CAAP bans on patient liability, treatment adherence, and treatment persistence.

METHODS

This was a retrospective cohort study using administrative claims recorded in the IQVIA PharMetrics Plus database. Data were extracted for patients with fully insured commercial plans receiving autoimmune or multiple sclerosis drugs between January 1, 2017, and December 31, 2021. Patient liability was defined as the difference in insurer allowed and paid amounts. Treatment adherence was measured as the proportion of days covered over a 1-year period, with "adherent" defined as a proportion of days covered greater than or equal to 80%. Treatment persistence was defined as time from treatment initiation to discontinuation (a period of 60 days without supply of treatment). The analysis compared differences in outcomes in states that implemented a CAAP ban during the study period (Arizona, Georgia, Illinois, Virginia, West Virginia) with states that did not, for before and after the date of ban.

RESULTS

States that implemented a CAAP ban had relative reductions in patient liability after the first 2 months, which ranged from 41% to 63%, with monthly savings ranging from $128 to $520. Patients in states with a CAAP ban had 14% greater odds of being adherent to their treatment after policy implementation than patients in states without a CAAP ban and a 13% reduction in risk of discontinuing.

CONCLUSIONS

The implementation of state legislation to restrict the use of CAAPs in state-regulated plans was associated with reductions in patient liability and improvements in treatment adherence and persistence for the 5 states that were early implementers of a CAAP ban. These results may offer insights for states that have recently implemented a CAAP ban, as well as for those considering enacting similar legislation.

The Associations of Prescription Drug Insurance and Cost-Sharing With Drug Use, Health Services Use, and Health: A Systematic Review of Canadian Studies

OBJECTIVES

In Canada, public insurance for physician and hospital services, without cost-sharing, is provided to all residents. Outpatient prescription drug coverage, however, is provided through a patchwork system of public and private plans, often with substantial cost-sharing, which leaves many underinsured or uninsured.

METHODS

We conducted a systematic review to examine the association of drug insurance and cost-sharing with drug use, health services use, and health in Canada. We searched 4 electronic databases, 2 grey literature databases, 5 specialty journals, and 2 working paper repositories. At least 2 reviewers independently screened articles for inclusion, extracted characteristics, and assessed risk of bias.

RESULTS

The expansion of drug insurance was associated with increases in drug use, individuals who reported drug insurance generally reported higher drug use, and increases in and higher levels of drug cost-sharing were associated with lower drug use. Although a number of studies found statistically significant associations between drug insurance or cost-sharing and health services use, the magnitudes of these associations were generally fairly small. Among 5 studies that examined the association of drug insurance and cost-sharing with health outcomes, 1 found a statistically significant and clinically meaningful association. We did not find that socioeconomic status or sex were effect modifiers; there was some evidence that health modified the association between drug insurance and cost-sharing and drug use.

CONCLUSIONS

Increased cost-sharing is likely to reduce drug use. Universal pharmacare without cost-sharing may reduce inequities because it would likely increase drug use among lower-income populations relative to higher-income populations.

Unintended consequences of healthcare reform in South Korea: evidence from a regression discontinuity in time design

BACKGROUND

To address concerns over the financial stability of South Korea's National Health Insurance (NHI) programme, the government transitioned from an outpatient copayment system to a coinsurance system in 2007. This policy aimed to reduce healthcare overutilization by increasing patients' financial responsibility for outpatient services.

METHODS

Using comprehensive data on NHI beneficiaries, this study employs a regression discontinuity in time (RDiT) design to assess the policy's impact on outpatient healthcare utilization and expenditures. We focus on changes in overall outpatient visits, average healthcare cost per visit and total outpatient healthcare expenditures.

RESULTS

Our findings indicate that the transition from outpatient copayment to coinsurance led to a substantial increase in outpatient healthcare utilization (up to 90%) while decreasing medical expenditures per visit by 23%. The policy shift incentivized beneficiaries to seek more medical treatments during the grace period and enroll in supplemental private health insurance, which provided access to additional medical services at lower marginal costs.

CONCLUSIONS

The policy change and the emergence of supplemental private insurance contributed to moral hazard and adverse selection issues, culminating in South Korea becoming the country with the highest per capita utilization of outpatient health services worldwide since 2012. This study underscores the importance of carefully considering the unintended consequences of policy interventions in the healthcare sector.

Real price of health-experiences of out-of-pocket costs in Australia: protocol for a systematic review

INTRODUCTION

Australians have substantial out-of-pocket (OOP) health costs compared with other developed nations, even with universal health insurance coverage. This can significantly affect access to care and subsequent well-being, especially for priority populations including those on lower incomes or with multimorbidity and chronic illness. While it is known that high OOP healthcare costs may contribute to poorer health outcomes, it is not clear exactly how these expenses are experienced by people with chronic illnesses. Understanding this may provide critical insights into the burden of OOP costs among this population group and may highlight policy gaps.

METHOD AND ANALYSIS

A systematic review of qualitative studies will be conducted using Pubmed, CINAHL Complete (EBSCO), Cochrane Library, PsycINFO (Ovid) and EconLit from date of inception to June 2022. Primary outcomes will include people's experiences of OOP costs such as their preferences, priorities, trade-offs and other decision-making considerations. Study selection will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and methodological appraisal of included studies will be assessed using the Critical Appraisal Skills Programme. A narrative synthesis will be conducted for all included studies.

ETHICS AND DISSEMINATION

Ethics approval was not required given this is a systematic review that does not include human recruitment or participation. The study's findings will be disseminated through conferences and symposia and shared with consumers, policymakers and service providers, and published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42022337538.

A conceptual model of health insurance stability in the United States health care system

In the U.S. health care system, people under age 65 are at risk of losing and regaining health insurance coverage over their lifetimes, which has important consequences for their physical and mental health. Despite the importance of insurance stability, we have an incomplete understanding about the complex factors influencing whether people lose and regain coverage. To advance our understanding of the dynamics of health insurance coverage and guide future research, our purpose is to present a new conceptual model of health insurance stability, where instability is defined as a person’s loss or change of coverage, which can occur more than once in a lifetime. Drawing from theory and evidence in the literature, we posit that personal and plan characteristics, the health system, and the environmental context – economic, social/cultural, political/judicial, and geographic – drive health insurance stability over the life course and are understudied. Studies are needed to identify the populations most at risk of experiencing insurance instability and vulnerability in health outcomes that results from such insecurity, which may suggest reforms and health policies at the individual, health system, or environment levels to reduce those risks.

Factors Associated with Willingness to Pay for Cost-Sharing under Universal Health Coverage Scheme in Yogyakarta, Indonesia: A Cross-Sectional Survey

BACKGROUND

National Health Insurance (NHI) in Indonesia requires an appropriate cost-sharing policy, particularly for diseases that require the largest financing. This study examined factors that influence willingness to pay (WTP) for cost-sharing under the universal health coverage scheme among patients with catastrophic illnesses in Yogyakarta, Indonesia.

METHODS

This was a cross-sectional study using structured questionnaires through direct interviews. The factors related to the WTP for cost-sharing under the NHI scheme in Indonesia were identified by a bivariable logistic regression analysis.

RESULTS

Two out of every five (41.2%) participants had willingness to pay for cost-sharing. Sex [AOR = 0.69 (0.51, 0.92)], education [AOR = 1.54 (0.67, 3.55)], family size [AOR = 1.71 (1.07, 2.73)], occupation [AOR = 1.35 (0.88, 2.07)], individual income [AOR = 1.50 (0.87, 2.61)], household income [AOR = 1.47 (0.90, 2.39)], place of treatment [AOR = 2.54 (1.44, 4.45)], a health insurance plan [AOR = 1.22 (0.87, 1.71)], and whether someone receives an inpatient or outpatient service [AOR = 0.23 (0.10, 0.51)] were found to affect the WTP for a cost-sharing scheme with p < 0.05.

CONCLUSION

Healthcare (place of treatment, health insurance plan, and whether someone receives an inpatient or outpatient service) and individual socioeconomic (sex, educational, family size, occupational, income) factors were significantly related to the WTP for cost-sharing.

Understanding patient and physician responses to various cost-sharing programs for prescription drugs in South Korea: A multilevel analysis

Introduction

Patient and/or physician responses are a pivotal issue in designing rational cost-sharing programs under health insurance systems.

Objectives

This study aims to understand patient and/or physician responses to cost-sharing programs designed for prescription drugs in South Korea.

Methods

As a framework, we took advantage of a tiered cost-sharing program, including from copayment to coinsurance (threshold 1) and reduced coinsurance (threshold 2). Given the hierarchical structure of prescriptions nested within patients, we utilized a multilevel analysis to assess effects of various cost-sharing programs on patient and/or physician responses using National Health Insurance claims data from 2018.

Results

We found that a tiered cost-sharing program was effective in changing the behaviors of patients and/or physicians. Threshold 1 was found to be more effective than threshold 2 in changing their behaviors. At the prescription level, sensitivity to cost-sharing programs was associated with prescribed days of treatment and locations of prescription. In a similar vein, sensitivity to cost-sharing programs was associated with gender and age group of patients.

Conclusion

A simplified cost-sharing program with extended intervals should be considered to rationalize cost-sharing programs. Specifically, a cost-sharing program designed for long-term prescriptions for chronic diseases together with an emphasis on cost transparency is required to better guide price-conscious decisions by patients and/or physicians.

Health Savings Accounts No Longer Promote Consumer Cost-Consciousness

Two decades ago Congress enabled Americans to open tax-favored health savings accounts (HSAs) in conjunction with qualifying high-deductible health plans (HDHPs). This HSA tax break is regressive: Higher-income Americans are more likely to have HSAs and fund them at higher levels. Proponents, however, have argued that this regressivity is offset by reductions in wasteful health care spending because consumers with HDHPs are more cost-conscious in their use of care. Using published sources and our own analysis of National Health Interview Survey data, we argue that HSAs no longer appreciably achieve this cost-consciousness aim because cost sharing has increased so much in non-HSA-qualified plans. Indeed, people who have HDHPs with HSAs are becoming less likely than others with private insurance to report financial barriers to care. In sum, promised gains in efficiency from HSAs have not borne out, so it is difficult to justify maintaining this regressive tax break.

A systematic umbrella review of the association of prescription drug insurance and cost-sharing with drug use, health services use, and health

BACKGROUND

Increasing spending and use of prescription drugs pose an important challenge to governments that seek to expand health insurance coverage to improve population health while controlling public expenditures. Patient cost-sharing such as deductibles and coinsurance is widely used with aim to control healthcare expenditures without adversely affecting health.

METHODS

We conducted a systematic umbrella review with a quality assessment of included studies to examine the association of prescription drug insurance and cost-sharing with drug use, health services use, and health. We searched five electronic bibliographic databases, hand-searched eight specialty journals and two working paper repositories, and examined references of relevant reviews. At least two reviewers independently screened the articles, extracted the characteristics, methods, and main results, and assessed the quality of each included study.

RESULTS

We identified 38 reviews. We found consistent evidence that having drug insurance and lower cost-sharing among the insured were associated with increased drug use while the lack or loss of drug insurance and higher drug cost-sharing were associated with decreased drug use. We also found consistent evidence that the poor, the chronically ill, seniors and children were similarly responsive to changes in insurance and cost-sharing. We found that drug insurance and lower drug cost-sharing were associated with lower healthcare services utilization including emergency room visits, hospitalizations, and outpatient visits. We did not find consistent evidence of an association between drug insurance or cost-sharing and health. Lastly, we did not find any evidence that the association between drug insurance or cost-sharing and drug use, health services use or health differed by socioeconomic status, health status, age or sex.

CONCLUSIONS

Given that the poor or near-poor often report substantially lower drug insurance coverage, universal pharmacare would likely increase drug use among lower-income populations relative to higher-income populations. On net, it is probable that health services use could decrease with universal pharmacare among those who gain drug insurance. Such cross-price effects of extending drug coverage should be included in costing simulations.

User fee removal for the poor: a qualitative study to explore policies for social health assistance in Iran

Introduction

Removal of user fee for vulnerable people reduces the financial barriers associated with healthcare payments, which, in turn, improves health outcomes and promotes health equity. This study sought to provide policy strategies to reduce user fee at the point of service delivery for the poor in Iran.

Methods

This is a qualitative study carried out in 2018. The purposive sampling method was applied, and 33 experts with relevant and valuable experiences and maximum variation to obtain representativeness and rich data were interviewed. Trustworthiness criteria were used to assure the quality of the results. The data were analyzed based on thematic analysis using the MAXQDA10 software.

Results

The most important issue regarding financial protection against user fee for the poor in Iran is policy integration and cohesion. Differences in access to financial support for user fee coverage among different groups of the poor have led to inequalities in access and financial protection among the poor. The suggested protection policies against the user fee at the point of service delivery in Iran can be categorized into three main categories: 1) basic health social insurance instruments, 2) free health services to the poor outside of the health insurance system, and 3) complementary insurance mechanisms.

Conclusion

Implementing a cohesive social assistance policy for all disadvantaged groups is needed to address inequalities in financial protection against user fee payment among the poor in Iran. Reducing user fee through mechanisms such as deductible cap, stop-loss, variable user fee and sliding fee scale can improve financial protection and enhance healthcare utilization among the poor. A user fee exemption is not enough to remove barriers to access to service for the poor, as other costs such as transportation expenditures and informal payments also put financial pressure on them. Therefore, financial support for the poor should be designed in a comprehensive protection package to reduce out-of-pocket payments for healthcare services, and indirect costs associated with healthcare utilization.

How important is income in explaining individuals having forgone healthcare due to cost-sharing payments? Results from a mixed methods sequential explanatory study

Background

Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to having forgone healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better.

Methods

Survey data was collected from a Dutch panel of regular users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics, i.e., personal characteristics, health, educational level, sense of mastery and financial situation. Semi-structured interviews (n = 5) were conducted with those who had forgone healthcare. The verbatim transcribed interviews were thematically analyzed.

Results

Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had forgone healthcare because of the deductible requirement. The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (odds ratios of higher income categories relative to the lowest income category (reference): 0.29–0.49). However, dominance analyses revealed that financial leeway was more important than income: financial leeway contributed the most (34.8%) to the model’s overall McFadden’s pseudo-R2 (i.e., 0.123), followed by income (25.6%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes that affected the patient’s decision whether to use healthcare: financial barriers, structural barriers related to the complex design of cost-sharing programs, individual considerations of the patient, and the perceived lack of control regarding treatment choices within a given treatment trajectory. Furthermore, “having forgone healthcare” seemed to have a negative connotation.

Conclusion

Our findings show that financial leeway is more important than income with respect to having forgone recommended healthcare due to cost-sharing payments, and that other factors such as the perceived necessity of healthcare also matter. Our findings imply that solely adapting cost-sharing programs to income levels will only get one so far. Our study underlines the need for a broader perspective in the design of cost-sharing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07527-z.

Copayment policy reforms and effective care utilization by patients with persistent asthma in Taiwan

OBJECTIVES

Reforms to the Taiwan National Health Insurance copayment scheme in 2005 imposed a notable increase in the cost of outpatient visits. This provided an ideal situation to determine whether such reforms lead to a reduction in the utilization of effective care by patients with persistent asthma.

METHODS

This study applied the pretest-posttest non-randomized control group design in our analysis of nationwide claims data (2002 to 2010). Based on propensity score matching, the patients were divided into two groups, subject and not subject to copayment reform. Medication Management for People with Asthma measure was used to identify patients with persistent asthma and instances of effective care.

RESULTS

Matching yielded a final panel of 7,890 individuals with persistent asthma (3,945 individuals in each cohort) eligible for the study. GEE analysis revealed that policy reforms had significant effects over the short-term (OR = 0.745, p < 0.05), medium-term (OR = 0.752, p < 0.01), and long-term (OR = 0.721, p < 0.01).

CONCLUSIONS

Reforms to copayment policy were significantly correlated with a reduction in the utilization of effective care by patients with persistent asthma over the short-, medium- and long-term. Government should develop implementation strategies aimed at protecting the economically disadvantaged patients.

Characteristics of US Adults Who Would Be Recommended for Lifestyle Modification Without Antihypertensive Medication to Manage Blood Pressure

BACKGROUND

The 2017 American College of Cardiology / American Heart Association Guideline for blood pressure (BP) management newly classifies millions of Americans with elevated BP or stage 1 hypertension for recommended lifestyle modification alone (without pharmacotherapy). This study characterized these adults, including their cardiovascular disease risk factors, barriers to lifestyle modification, and healthcare access.

METHODS

This cross-sectional study examined nationally representative National Health and Nutrition Examination Survey data, 2013-2016, on 10,205 US adults aged ≥18, among whom 2,081 had elevated BP or stage 1 hypertension and met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone.

RESULTS

An estimated 22% of US adults (52 million) would be recommended for lifestyle modification alone. Among these, 58% were men, 43% had obesity, 52% had low-quality diet, 95% consumed excess sodium, 43% were physically inactive, and 8% consumed excess alcohol. Many reported attempting lifestyle changes (range: 39%-60%). Those who reported receiving health professional advice to lose weight (adjusted prevalence ratio 1.21, 95% confidence interval 1.06-1.38), reduce sodium intake (2.33, 2.00-2.72), or exercise more (1.60, 1.32-1.95) were significantly more likely to report attempting changes. However, potential barriers to lifestyle modification included 28% of adults reporting disability, asthma, or arthritis. Additionally, 20% had no health insurance and 22% had no healthcare visits in the last year.

CONCLUSIONS

One-fifth of US adults met 2017 ACC/AHA BP Guideline criteria for lifestyle modification alone, and many reported attempting behavior change. However, barriers exist such as insurance gaps, limited access to care, and physical impairment.

Association of daily copayments with use of hospital care among medicare advantage enrollees

BACKGROUND

While the traditional Medicare program imposes a deductible for hospital admissions, many Medicare Advantage plans have instituted per-diem copayments for hospital care. Little evidence exists about the effects of changes in cost-sharing for hospital care among the elderly. Changing inpatient benefits from a deductible to a per diem may benefit enrollees with shorter lengths of stay, but adversely affect the out-of-pocket burden for hospitalized enrollees with longer lengths of stay.

METHODS

We used a quasi-experimental difference-in-differences study to compare longitudinal changes in proportion hospitalized, inpatient admissions and days per 100 enrollees, and hospital length of stay between enrollees in MA plans that changed inpatient benefit from deductible at admission to per diem, intervention plans, and enrollees in matched control plans - similar plans that maintained inpatient deductibles. The study population included 423,634 unique beneficiaries enrolled in 23 intervention plans and 36 matched control plans in the 2007-2010 period.

RESULTS

The imposition of per-diem copayments were associated with adjusted declines of 1.3 admissions/100 enrollees (95% CI - 1.8 to - 0.9), 6.9 inpatient days/100 enrollees (95% CI - 10.1 to - 3.8) and 0.7 percentage points in the probability of hospital admission (95% CI - 1.0 to - 0.4), with no significant change in adjusted length of stay in intervention plans relative to control plans. For persons with 2 or more hospitalizations in the year prior to the cost-sharing change, adjusted declines were 3.5 admissions/100 (95% CI - 8.4 to 1.4), 31.1 days/100 (95% CI - 75.2 to 13.0) and 2.2 percentage points in the probability of hospitalization (95% CI - 3.8 to - 0.6) in intervention plans relative to control plans.

CONCLUSIONS

Instituting per-diem copayments was associated with reductions in number of admissions and hospital stays, but not length of stay once admitted. Effects of inpatient cost-sharing changes were magnified for persons with greater baseline use of hospital care.

Prevalence of depressive symptoms among older adults who reported medical cost as a barrier to seeking health care: findings from a nationally representative sample

BACKGROUND

Older adults aged 65 and over will make up more than 20% of U.S. residents by 2030, and in 2050, this population will reach 83.7 million. Depression among older adults is a major public health concern projected to be the second leading cause of disease burden. Despite having Medicare, and other employer supplements, the burden of out of pocket healthcare expenses may be an important predictor of depression. The current study aims to investigate whether delay in seeing a doctor when needed but could not because of medical cost is significantly associated with symptoms of current depression in older adults.

METHODS

Cross-sectional data from the 2011 Behavioral Risk Factor Surveillance System (BFRSS) from 12 states and Puerto Rico were used for this study (n = 24,018).

RESULTS

The prevalence of symptoms of current depression among older adults who reported medical cost as a barrier to seeking health care was significantly higher (17.8%) when compared to older adults who reported medical cost not being a barrier to seeking health care (5.5%). Older adults who reported medical cost as a barrier to seeking health care were more likely to report current depressive symptoms compared to their counterparts [Adjusted Odds Ratio (AOR): 2.2 [95% CI: 1.5-3.3]).

CONCLUSIONS

Older adults (≥ 65 years of age) who experience the burden of medical cost for health care are significantly more likely to report symptoms of depression. Health care professionals and policymakers should consider effective interventions to improve access to health care among older adults.

Effectiveness of Medicare cost-sharing elimination for Cancer screening on utilization

Background

The Patient Protection and Affordable Care Act (ACA) eliminated the cost-sharing requirement for several preventive cancer screenings. This study examined the cancer screening utilization of mammogram, Pap smear and colonoscopy in Medicare fee-for-service (FFS) under the ACA.

Methods

The primary data were the 2007–2013 Medicare Current Beneficiary Survey linked to FFS claims. The effect of the cost-sharing removal on the probability of receiving a preventive cancer screening test was estimated using a logistic regression, separately for each screening test, adjusting for the complex survey design. The model was also separately estimated for different socioeconomic and race/ethnic groups.

The study sample included beneficiaries with Part B coverage for the entire calendar year, excluding beneficiaries in Medicaid or Medicare Advantage plans. Beneficiaries with a claims-documented or self-reported history of targeted cancers, who were likely to have diagnostic tests or have surveillance screenings were excluded.

The screening measures were constructed separately following Medicare coverage and U.S. Preventive Services Task Force (USPSTF) recommendations. We measured the screening utilization outcome drawing from claims data, as well as using the self-reported survey data.

Results

After the cost-sharing removal policy, we found no statistically significant difference in a beneficiary’s probability of receiving a colonoscopy (transition period: OR = 1.08, 95% CI = 0.90–1.29; post-policy period: OR = 1.08, 95% CI = 0.83–1.42), a mammogram (transition period: OR = 1.03, 95% CI = 0.91–1.17; post-policy period: OR = 1.07, 95% CI = 0.88–1.30), or a biennial Pap smear (transition period: OR = 0.87, 95% CI = 0.69–1.09; post-policy period: OR = 0.72, 95% CI = 0.51–1.03) in claims-based measures following Medicare coverage. Similarly, we found null effects of the policy change on utilization of colonoscopy among enrollees 50–75 years old, biennial mammograms by women 50–74, and triennial Pap smear tests among women 21–65 in claims-based measures according to USPSTF. The findings from survey-based measures were consistent with the estimates from claims-based measures, except that the use of Pap smear declined since 2011. Further, the policy change did not increase utilization in patients with disadvantaged socioeconomic characteristics. Yet the disparate patterns in adjusted screening rates by socioeconomic status and race/ethnicity persisted over time.

Conclusions

Removing out-of-pocket costs for screenings did not provide enough incentives to increase the screening rates among Medicare beneficiaries.

Impact of The Affordable Care Act's Elimination of Cost-Sharing on the Guideline-Concordant Utilization of Cancer Preventive Screenings in the United States Using Medical Expenditure Panel Survey

Currently available evidence regarding the association of the Affordable Care Act’s (ACA) elimination of cost-sharing and the utilization of cancer screenings is mixed. We determined whether the ACA’s zero cost-sharing policy affected the guideline-concordant utilization of cancer screenings, comparing adults (≥21 years) from 2009 with 2011–2014 data from the Medical Expenditure Panel Survey. Study participants were categorized as: 21–64 years with any private insurance, ≥65 years with Medicare only, and 21–64 years uninsured, with a separate sample for each type of screening test. Adjusted weighted prevalence and prevalence ratios (PR (95%CI)) were estimated. In 2014 (vs. 2009), privately-insured women reported 2% (0.98 (0.97–0.99)) and 4% (0.96 (0.93–0.99)) reduction in use of Pap tests and mammography, respectively. Privately-insured non-Hispanic Asian women had 16% (0.84 (0.74–0.97)) reduction in mammography in 2014 (vs. 2009). In 2011 (vs. 2009), privately-insured and Medicare-only men reported 9% (1.09 (1.03–1.16)) and 13% (1.13 (1.02–1.25)) increases in colorectal cancer (CRC) screenings, respectively. Privately-insured women reported a 6–7% rise in 2013–2014 (vs. 2009), and Hispanic Medicare beneficiaries also reported 40–44%, a significant rise in 2011–2014 (vs. 2009), in the utilization of CRC screenings. While the guideline-concordant utilization of Pap tests and mammography declined in the post-ACA period, the elimination of cost-sharing appeared to have positively affected CRC screenings of privately-insured males, females, and Hispanic Medicare-only beneficiaries. Greater awareness about the zero cost-sharing policy may help in increasing the uptake of cancer screenings.

High-cost sharing policies and non-urgent emergency department visits

PURPOSE

The purpose of this paper is to examine whether high-cost-sharing ambulatory care policies affect non-urgent emergency department (ED) care utilization differently among individuals with and without chronic conditions.

DESIGN/METHODOLOGY/APPROACH

This retrospective cohort study used 2010-2011 US Medical Expenditure Panel Survey data. Difference-in-difference methods, multivariate logit model and survey procedures were employed. Time lag effect was used to address endogeneity concerns.

FINDINGS

The sample included 4,347 individuals. Difference in non-urgent ED visits log odds between high- and low-cost-sharing policies was not significantly different between chronically ill and non-chronically ill individuals ( β=-0.48, p=0.42). Sensitivity analysis with 15 and 25 percent cost-sharing levels also generated consistent insignificant results ( p=0.33 and p=0.31, respectively). Ambulatory care incidence rates were not significantly different between high- and low-cost-sharing groups among chronically ill people (incidence rate ratio=0.849, p=0.069).

PRACTICAL IMPLICATIONS

High-cost-sharing ambulatory care policies were not associated with increased non-urgent ED care utilization among chronically ill and healthy people. The chronically ill patients may have retained sizable ambulatory care that was necessary to maintain their health. Health plans or employers may consider low-level cost-sharing policies for ambulatory care among chronically ill enrollees or employees.

ORIGINALITY/VALUE

Findings contribute to insurance benefit design; i.e., whether high-cost-sharing ambulatory care policies should be implemented among chronically ill enrollees to maintain their health and save costs for health plans.

Patients' attitudes toward copayments as a steering tool-results from a qualitative study in Norway and Germany

BACKGROUND

Copayments are implemented in many health care systems. The effect of copayments differs between countries. Up to now, patients' attitudes regarding copayments are mainly unknown.

OBJECTIVES

Thus, the goal of our analysis was to explore adult patients' attitudes in Germany and Norway towards copayments as a steering tool.

METHODS

We conducted a qualitative comparative study. Episodic interviews were conducted with 40 patients in Germany and Norway. The interviews were analysed by thematic coding in the framework of grounded theory. All text segments related to copayments were analysed in depth for emerging topics and types.

RESULTS

We found three dimensions of patients' attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. The perceived steering effect consists of three types: having been influenced by copayments, not having experienced any influence and the experience of other persons to be influenced. The category comprehensibility describes that not all patients understand rules and regulations of copayments and its caps. The assessment of copayments consists of nine subcategories, three of which are rather negative and six of which are rather positive. In all three dimensions the patterns between the German and Norwegian sub-samples differ considerably.

CONCLUSIONS

The results of our study point at the importance of communicating clear rules for copayments which are easily comprehensible.

Effect of High-Deductible Insurance on High-Acuity Outcomes in Diabetes: A Natural Experiment for Translation in Diabetes (NEXT-D) Study

OBJECTIVE

High-deductible health plans (HDHPs) are now the predominant commercial health insurance benefit in the U.S. We sought to determine the effects of HDHPs on emergency department and hospital care, adverse outcomes, and total health care expenditures among patients with diabetes.

RESEARCH DESIGN AND METHODS

We applied a controlled interrupted time-series design to study 23,493 HDHP members with diabetes, aged 12-64, insured through a large national health insurer from 2003 to 2012. HDHP members were enrolled for 1 year in a low-deductible (≤$500) plan, followed by 1 year in an HDHP (≥$1,000 deductible) after an employer-mandated switch. Patients transitioning to HDHPs were matched to 192,842 contemporaneous patients whose employers offered only low-deductible coverage. HDHP members from low-income neighborhoods (n = 8,453) were a subgroup of interest. Utilization measures included emergency department visits, hospitalizations, and total (health plan plus member out-of-pocket) health care expenditures. Proxy health outcome measures comprised high-severity emergency department visit expenditures and high-severity hospitalization days.

RESULTS

After the HDHP transition, emergency department visits declined by 4.0% (95% CI -7.8, -0.1), hospitalizations fell by 5.6% (-10.8, -0.5), direct (nonemergency department-based) hospitalizations declined by 11.1% (-16.6, -5.6), and total health care expenditures dropped by 3.8% (-4.3, -3.4). Adverse outcomes did not change in the overall HDHP cohort, but members from low-income neighborhoods experienced 23.5% higher (18.3, 28.7) high-severity emergency department visit expenditures and 27.4% higher (15.5, 39.2) high-severity hospitalization days.

CONCLUSIONS

After an HDHP switch, direct hospitalizations declined by 11.1% among patients with diabetes, likely driving 3.8% lower total health care expenditures. Proxy adverse outcomes were unchanged in the overall HDHP population with diabetes, but members from low-income neighborhoods experienced large, concerning increases in high-severity emergency department visit expenditures and hospitalization days.

The Rise and Fall in Out-of-Pocket Costs in Australia: An Analysis of the Strengthening Medicare Reforms

After a period of steady decline, out-of-pocket (OOP) costs for general practitioner (GP) consultations in Australia began increasing in the mid-1990s. Following the rising community concerns about the increasing costs, the Australian Government introduced the Strengthening Medicare reforms in 2004 and 2005, which included a targeted incentive for GPs to charge zero OOP costs for consultations provided to children and concession cardholders (older adults and the poor), as well as an increase in the reimbursement for all GP visits. This paper examines the impact of those reforms using longitudinal survey and administrative data from a large national sample of women. The findings suggest that the reforms were effective in reducing OOP costs by an average of $A0.40 per visit. Decreases in OOP costs, however, were not evenly distributed. Those with higher pre-reform OOP costs had the biggest reductions in OOP costs, as did those with concession cards. However, results also reveal increases in OOP costs for most people without a concession card. The analysis suggests that there has been considerable heterogeneity in GP responses to the reforms, which has led to substantial changes in the fees charged by doctors and, as a result, the OOP costs incurred by different population groups. Copyright © 2016 John Wiley & Sons, Ltd.

Drivers of poor medical care

The global ubiquity of overuse and underuse of health-care resources and the gravity of resulting harms necessitate an investigation of drivers to inform potential solutions. We describe the network of influences that contribute to poor care and suggest that it is driven by factors that fall into three domains: money and finance; knowledge, bias, and uncertainty; and power and human relationships. In each domain the drivers operate at the global, national, regional, and individual level, and are modulated by the specific contexts within which they act. We discuss in detail drivers of poor care in each domain.

Bleeding Hearts, Profiteers, or Both: Specialist Physician Fees in an Unregulated Market

This study shows that, in an unregulated fee-setting environment, specialist physicians practise price discrimination on the basis of their patients' income status. Our results are consistent with profit maximisation behaviour by specialists. These findings are based on a large population survey that is linked to administrative medical claims records. We find that, for an initial consultation, specialist physicians charge their high-income patients AU$26 more than their low-income patients. While this gap equates to a 19% lower fees for the poorest patients (bottom 25% of the household income distribution), it is unlikely to remove the substantial financial barriers they face in accessing specialist care. There are large variations across specialties, with neurologists exhibiting the largest fee gap between the high-income and low-income patients. Several possible channels for deducing the patient's income are examined. We find that patient characteristics such as age, health concession card status and private health insurance status are all used by specialists as proxies for income status. These characteristics are particularly important to further practise price discrimination among the low-income patients but are less relevant for the high-income patients. Copyright © 2016 John Wiley & Sons, Ltd.

The effect of increasing the coinsurance rate on outpatient utilization of healthcare services in South Korea

BACKGROUND

The Korean healthcare system is composed of costly and inefficient structures that fail to adequately divide the functions and roles of medical care organizations. To resolve this matter, the government reformed the cost-sharing policy in November of 2011 for the management of outpatients visiting general or tertiary hospitals with comparatively mild diseases. The purpose of the present study was to examine the impact of increasing the coinsurance rate of prescription drug costs for 52 mild diseases at general or tertiary hospitals on outpatient healthcare service utilization.

METHODS

The present study used health insurance claim data collected from 2010 to 2013. The study population consisted of 505,691 outpatients and was defined as those aged 20-64 years who had visited medical care organizations for the treatment of 52 diseases both before and after the program began. To examine the effect of the cost-sharing policy on outpatient healthcare service utilization (percentage of general or tertiary hospital utilization, number of outpatient visits, and outpatient medical costs), a segmented regression analysis was performed.

RESULTS

After the policy to increase the coinsurance rate on prescription drug costs was implemented, the number of outpatient visits at general or tertiary hospitals decreased (β = -0.0114, p < 0.0001); however, the number increased at hospitals and clinics (β = 0.0580, p < 0.0001). Eventually, the number of outpatient visits to hospitals and clinics began to decrease after policy initiation (β = -0.0018, p < 0.0001). Outpatient medical costs decreased for both medical care organizations (general or tertiary hospitals: β = -2913.4, P < 0.0001; hospitals or clinics: β = -591.35, p < 0.0001), and this decreasing trend continued with time.

CONCLUSIONS

It is not clear that decreased utilization of general or tertiary hospitals has transferred to that of clinics or hospitals due to the increased cost-sharing policy of prescription drug costs. This result indicates the cost-sharing policy, intended to change patient behaviors for healthcare service utilization, has had limited effects on rebuilding the healthcare system and the function of medical care organizations.

How do high cost-sharing policies for physician care affect inpatient care use and costs among people with chronic disease?

Rapidly rising health care costs continue to be a significant concern in the United States. High cost-sharing strategies thus have been widely used to address rising health care costs. Since high cost-sharing policies can reduce needed care as well as unneeded care use, it raises the concern whether these policies for physician care are a good strategy for controlling costs among chronically ill patients, especially whether utilization and costs in inpatient care will increase in response. This study examined whether high cost sharing in physician care affects inpatient care utilization and costs differently between individuals with and without chronic conditions. Findings from this study will contribute to the insurance benefit design that can control care utilization and save costs of chronically ill individuals. Prior studies suffered from gaps that limit both internal validity and external validity of their findings. This study has its unique contributions by filling these gaps jointly. The study used data from the 2007 Medical Expenditure Panel Survey, a nationally representative sample, with a cross-sectional study design. Instrumental variable technique was used to address the endogeneity between health care utilization and cost-sharing levels. We used negative binomial regression to analyze the count data and generalized linear models for costs data. To account for national survey sampling design, weight and variance were adjusted. The study compared the effects of high cost-sharing policies on inpatient care utilization and costs between individuals with and without chronic conditions to answer the research question. The final study sample consisted of 4523 individuals; among them, 752 had hospitalizations. The multivariate analysis demonstrated consistent patterns. Compared with low cost-sharing policies, high cost-sharing policies for physician care were not associated with a greater increase in inpatient care utilization (P = .86 for chronically ill people and P = .67 for healthy people, respectively) and costs (P = .38 for chronically ill people and P = .68 for healthy people, respectively). The sensitivity analysis with a 10% cost-sharing level also generated consistent insignificant results for both chronically ill and healthy groups. Relative to nonchronically ill individuals, chronically ill individuals may increase their utilization and expenditures of inpatient care to a similar extent in response to increased physician care cost sharing. This may be due to cost pressure from inpatient care and short observation window. Although this study did not find evidence that high cost-sharing policies for physician care increase inpatient care differently for individuals with and without chronic conditions, interpretation of this finding should be cautious. It is possible that in the long run, these sick people would demonstrate substantial demands for medical care and there could be a total cost increase for health plans ultimately. Health plans need to be cautious of policies for chronically ill enrollees.

Cost Sharing in Medicaid: Assumptions, Evidence, and Future Directions

Several states have received waivers to expand Medicaid to poor adults under the Affordable Care Act using more cost sharing than the program traditionally allows. We synthesize literature on the effects of cost sharing, focusing on studies of low-income U.S. populations from 1995 to 2014. Literature suggests that cost sharing has a deterrent effect on initiation of treatments, and can reduce utilization of ongoing treatments. Furthermore, cost sharing may be difficult for low-income populations to understand, patients often lack sufficient information to choose medical treatment, and cost sharing may be difficult to balance within the budgets of poor adults. Gaps in the literature include evidence of long-term effects of cost sharing on health and financial well-being, evidence related to effectiveness of cost sharing combined with patient education, and evidence related to targeted programs that use financial incentives for wellness. Literature underscores the need for evaluation of the effects of cost sharing on health status and spending, particularly among the poorest adults.

Do Gatekeeping Schemes Influence Health Care Utilization Behavior Among Patients With Different Educational Background? An Analysis of 13 European Countries

Gatekeeping has been introduced to regulate health care demand and to decrease existing educational inequalities in specialist utilization. This article aims to test whether these policy intentions are met effectively. By pooling two waves of the Survey of Health, Ageing, and Retirement in Europe (SHARE), this study performs a cross-country comparison of the impact of two different types of gatekeeping-obligatory referral and skip-and-pay schemes-on absolute and relative general practitioner and specialist utilization levels as well as their moderating effect on inequalities in health care utilization according to education. Results imply that skip-and-pay gatekeeping schemes are not successful in decreasing specialist use and, moreover, aggravate inequalities in health care use, according to education. These findings question the role of choice in health care and call for instruments other than gatekeeping to make health care more efficient and to buffer existing educational inequalities in health care use.

Lessons from state mandates of preventive cancer screenings

We use the 1997-2008 Medical Expenditure Panel Survey (MEPS) and variation in the timing of state mandates for coverage of colorectal, cervical, and prostate cancer screenings to investigate the behavioral and financial effects of mandates on privately insured adults. We find that state mandates did not result in increased rates of cancer screening. However, coverage of preventive care, whether mandated or not, moves the cost of care from the consumer's out-of-pocket expense to the premium, resulting in a cross-subsidy of users of the service by non-users. While some cross-subsidies are intentional, others may be unintentional. We find that users of cancer screening have higher levels of income and education, while non-users tend to be racial minorities, lack a usual source of care, and live in communities with fewer physicians per capita. These results suggest that coverage of preventive care may transfer resources from more advantaged individuals to less advantaged individuals.

Cost Sharing, Health Care Expenditures, and Utilization: An International Comparison

Health systems implement cost sharing to help reduce health care expenditure and utilization by discouraging the use of unnecessary health care services. We examine cost sharing in 28 countries in the Organisation for Economic Co-operation and Development from 1999 through 2009 in the areas of medical care, hospital care, and pharmaceuticals. We investigate associations between cost sharing, health care expenditures, and health care utilization and find no significant association between cost sharing and health care expenditures or utilization in these countries.

Emergency room (ER) referrals and health insurance in the United States

This article aims to determine how various health insurance policies affect the rate of emergency room (ER) referrals in the United States. The secondary data, gathered in National Health Measurement Study (NHMS) in 2008 and 2010, was used. The authors identify the relationships between health insurance and ER referrals by using zero-inflated binomial and zero-inflated Poisson regression. About 17% (2008) and 20% (2010) of the respondents had one or more ER referrals in the 2 years; those who were under coverage of governmental health insurance are more likely to refer ER than uninsured group. The differences in ER referrals that ended with hospital admission across different insurance policies are not significant. Health insurance is a remarkable factor in ER referrals; the coverage of health insurance plans can affect consuming the services provided in ER. Governmental insurance plans can increase ER referrals.

Cost-sharing, physician utilization, and adverse selection among Medicare beneficiaries with chronic health conditions

Pooled data from the 2007, 2009, and 2011/2012 California Health Interview Surveys were used to compare the number of self-reported annual physician visits among 36,808 Medicare beneficiaries ≥65 in insurance groups with differential cost-sharing. Adjusted for adverse selection and a set of health covariates, Medicare fee-for-service (FFS) only beneficiaries had similar physician utilization compared with HMO enrollees but fewer visits compared with those with supplemental (1.04, p = .001) and Medicaid (1.55, p = .003) coverage. FFS only beneficiaries in very good or excellent health had fewer visits compared with those of similar health status with supplemental (1.30, p = .001) or Medicaid coverage (2.15, p = .002). For subpopulations with several chronic conditions, FFS only beneficiaries also had fewer visits compared with beneficiaries with supplemental or Medicaid coverage. Observed differences in utilization may reflect efficient and necessary physician utilization among those with chronic health needs.

Lessons from Medicare coverage of colonoscopy and prostate-specific antigen test

Under the 1997 Balanced Budget Act, Medicare expanded coverage of colonoscopy and prostate-specific antigen tests from diagnostic and surveillance tests to preventive screenings. The preventive tests now are covered with no deductibles or copayments. Reducing out-of-pocket costs increases premiums, resulting in a subsidy to beneficiaries who use the service by nonusers, and by taxpayers who shoulder the bulk of Medicare's costs. Using Medicare fee-for-service claims and the Medicare Current Beneficiary Survey, we estimate the behavioral and financial consequences of these Balanced Budget Act coverage expansions. We find that fee-for-service Medicare-covered colonoscopies increased by 3.5 percentage points after the coverage expansion, and prostate-specific antigen tests increased by 6.8 percentage points. Beneficiaries with lower incomes, less education, and those lacking a usual source of care or supplemental insurance were less likely to use these tests. Therefore, they generally received much smaller net benefits from the coverage of colonoscopies than more advantaged beneficiaries.

Clinical Preventive Services Coverage and the Affordable Care Act

The Affordable Care Act requires many health plans to provide coverage for certain recommended clinical preventive services without charging copays or deductible payments. This provision could lead to greater uptake of many services that can improve health and save lives. Although the coverage provision is broad, there are many caveats that also apply. It is important for providers and public health professionals to understand the nuances of the coverage rules to help maximize their potential to improve population health.

Co-payments for health care: what is their real cost?

Based on the premise that current trends in healthcare spending are unsustainable, the Australian Government has proposed in the recent Budget the introduction of a compulsory $7 co-payment to visit a General Practitioner (GP), alongside increased medication copayments. This paper is based on a recent submission to the Senate Inquiry into the impact of out-of-pocket costs in Australia. It is based on a growing body of evidence highlighting the substantial economic burden faced by individuals and families as a result of out-of-pocket costs for health care and their flow-on effects on healthcare access, outcomes and long-term healthcare costs. It is argued that a compulsory minimum co-payment for GP consultations will exacerbate these burdens and significantly undermine the tenets of universal access in Medicare. Alternative recommendations are provided that may help harness unsustainable health spending while promoting an equitable and fair health system.

Financial barriers to care among low-income children with asthma: health care reform implications

IMPORTANCE

The Patient Protection and Affordable Care Act (ACA) includes subsidies that reduce patient cost sharing for low-income families. Limited information on the effects of cost sharing among children is available to guide these efforts.

OBJECTIVE

To examine the associations between cost sharing, income, and care seeking and financial stress among children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

A telephone survey in 2012 about experiences during the prior year within an integrated health care delivery system. Respondents included 769 parents of children aged 4 to 11 years with asthma. Of these, 25.9% of children received public subsidies; 21.7% were commercially insured with household incomes at or below 250% of the federal poverty level (FPL) and 18.2% had higher cost-sharing levels for all services (e.g., ≥$75 for emergency department visits). We classified children with asthma based on (1) current receipt of a subsidy (i.e., Medicaid or Children's Health Insurance Program) or potential eligibility for ACA low-income cost sharing or premium subsidies in 2014 (i.e., income ≤250%, 251%-400%, or >400% of the FPL) and (2) cost-sharing levels for prescription drugs, office visits, and emergency department visits. We examined the frequency of changes in care seeking and financial stress due to asthma care costs across these groups using logistic regression, adjusted for patient/family characteristics.

MAIN OUTCOMES AND MEASURES

Switching to cheaper asthma drugs, using less medication than prescribed, delaying/avoiding any office or emergency department visits, and financial stress (eg, cutting back on necessities) because of the costs of asthma care.

RESULTS

After adjustment, parents at or below 250% of the FPL with lower vs higher cost-sharing levels were less likely to delay or avoid taking their children to a physician's office visit (3.8% vs. 31.6%; odds ratio, 0.07 [95% CI, 0.01-0.39]) and the emergency department (1.2% vs. 19.4%; 0.05 [0.01-0.25]) because of cost; higher-income parents and those whose children were receiving public subsidies (eg, Medicaid) were also less likely to forego their children's care than parents at or below 250% of the FPL with higher cost-sharing levels. Overall, 15.6% of parents borrowed money or cut back on necessities to pay for their children's asthma care.

CONCLUSIONS AND RELEVANCE

Cost-related barriers to care among children with asthma were concentrated among low-income families with higher cost-sharing levels. The ACA's low-income subsidies could reduce these barriers for many families, but millions of dependents for whom employer-sponsored family coverage is unaffordable could remain at risk for cost-related problems because of ACA subsidy eligibility rules.

Copayments did not reduce medicaid enrollees' nonemergency use of emergency departments

Eager to reduce unnecessary use of hospital emergency departments by Medicaid enrollees, states are increasingly implementing cost sharing for nonemergency visits. This paper uses monthly data from the 2001-2006 Medical Expenditure Panel Surveys (MEPS) to examine how changes in nine states' copayment policies influence enrollees' use of emergency departments. The results suggest that requiring copayments for nonemergency visits did not decrease emergency department use by Medicaid enrollees. Future research should examine more closely the effects at the state level and investigate whether these copayments affected the use of other services, such as hospitalizations or visits to physicians by Medicaid enrollees.

Access to care after Massachusetts' health care reform: a safety net hospital patient survey

BACKGROUND

Massachusetts' health care reform substantially decreased the percentage of uninsured residents. However, less is known about how reform affected access to care, especially according to insurance type.

OBJECTIVE

To assess access to care in Massachusetts after implementation of health care reform, based on insurance status and type.

DESIGN AND PARTICIPANTS

We surveyed a convenience sample of 431 patients presenting to the Emergency Department of Massachusetts' second largest safety net hospital between July 25, 2009 and March 20, 2010.

MAIN MEASURES

Demographic and clinical characteristics, insurance coverage, measures of access to care and cost-related barriers to care.

KEY RESULTS

Patients with Commonwealth Care and Medicaid, the two forms of insurance most often newly-acquired under the reform, reported similar or higher utilization of and access to outpatient visits and rates of having a usual source of care, compared with the privately insured. Compared with the privately insured, a significantly higher proportion of patients with Medicaid or Commonwealth Care Type 1 (minimal cost sharing) reported delaying or not getting dental care (42.2 % vs. 27.1 %) or medication (30.0 % vs. 7.0 %) due to cost; those with Medicaid also experienced cost-related barriers to seeing a specialist (14.6 % vs. 3.5 %) or getting recommended tests (15.6 % vs. 5.9 %). Those with Commonwealth Care Types 2 and 3 (greater cost sharing) reported significantly more cost-related barriers to obtaining care than the privately insured (45.0 % vs. 16.0 %), to seeing a primary care doctor (25.0 % vs. 6.0 %) or dental provider (58.3 % vs. 27.1 %), and to obtaining medication (20.8 % vs. 7.0 %). No differences in cost-related barriers to preventive care were found between the privately and publicly insured.

CONCLUSIONS

Access to care improved less than access to insurance following Massachusetts' health care reform. Many newly insured residents obtained Medicaid or state subsidized private insurance; cost-related barriers to access were worse for these patients than for the privately insured.

The fox and the grapes: is real reform beyond reach in the United States?

As the challenges of maintaining (or, in the US case, attaining) affordable universal coverage multiply, the debate about what constitutes "real" reform intensifies in Western health care systems. The reality of reform, however, lies in the eyes of myriad beholders who variously enshrine consumer responsibility, changes in payment systems, reorganization, and other strategies -- or some encompassing combination of all of the above -- as the essential ingredient(s). This debate, increasingly informed by the agendas of health services researchers and health policy analysts, arguably serves as much or more to becloud as to clarify the practical options policy makers face and remains severely imbalanced with respect to the institutional sectors on which it concentrates, the fields of knowledge on which it draws, and the roles it envisions for markets and the state.

Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review

Background

Emergency department (ED) utilization has dramatically increased in developed countries over the last twenty years. Because it has been associated with adverse outcomes, increased costs, and an overload on the hospital organization, several policies have tried to curb this growing trend. The aim of this study is to systematically review the effectiveness of organizational interventions designed to reduce ED utilization.

Methodology/Principal Findings

We conducted electronic searches using free text and Medical Subject Headings on PubMed and The Cochrane Library to identify studies of ED visits, re-visits and mortality. We performed complementary searches of grey literature, manual searches and direct contacts with experts. We included studies that investigated the effectiveness of interventions designed to reduce ED visits and the following study designs: time series, cross-sectional, repeated cross-sectional, longitudinal, quasi-experimental studies, and randomized trial. We excluded studies on specific conditions, children and with no relevant outcomes (ED visits, re-visits or adverse events). From 2,348 potentially useful references, 48 satisfied the inclusion criteria. We classified the interventions in mutually exclusive categories: 1) Interventions addressing the supply and accessibility of services: 25 studies examined efforts to increase primary care physicians, centers, or hours of service; 2) Interventions addressing the demand for services: 6 studies examined educational interventions and 17 examined barrier interventions (gatekeeping or cost).

Conclusions/Significance

The evidence suggests that interventions aimed at increasing primary care accessibility and ED cost-sharing are effective in reducing ED use. However, the rest of the interventions aimed at decreasing ED utilization showed contradictory results. Changes in health care policies require rigorous evaluation before being implemented since these can have a high impact on individual health and use of health care resources. Systematic review registration: http://www.crd.york.ac.uk/PROSPERO. Identifier: CRD420111253

Effect of copayments on use of outpatient mental health services among elderly managed care enrollees

BACKGROUND

Recent parity legislation will require many insurers and the federal Medicare program to reduce mental health copayments, so that they are equivalent to copayments for other covered services. The effect of changes in mental health cost sharing has not been well studied, particularly among elderly populations.

OBJECTIVE

To examine the consequences of increasing and decreasing copayments on the use of outpatient mental health services among the elderly.

RESEARCH DESIGN

Difference-in-differences (DID) design comparing the use of outpatient mental health care in Medicare plans that changed mental health copayments compared with concurrent trends in matched control plans with unchanged copayments.

STUDY POPULATION

A total of 1,147,916 enrollees aged 65 years and older in 14 Medicare plans that increased copayments by ≥ 25%, 3 plans that decreased copayments by ≥ 25%, and 17 matched control plans with unchanged copayments.

RESULTS

In 14 plans that increased mental health copayments from a mean of $14.43 to $21.07, the proportion of enrollees who used mental health services remained at 2.2% in the year before and year after the increase (adjusted DID, 0.1 percentage points; 95% confidence interval, 0.0-0.1). Among 3 plans that decreased copayments from a mean of $25.00 to $8.33, utilization rates were 1.2% before and after the decrease (adjusted DID, 0.1 percentage points; 95% confidence interval, -0.2 to 0.3). Stratified analyses by age, gender, race, and presence of a disability yielded similar results.

CONCLUSIONS

Few older adults in managed care plans used outpatient mental health services. Among this population, increasing or decreasing mental health copayments had negligible effects on the likelihood of using outpatient mental health care.

Health care utilization and self-care behaviors of Medicare beneficiaries with diabetes: comparison of national and ethnically diverse underserved populations

Caring for persons with diabetes is expensive, and this burden is increasing. Little is known about service use, behaviors, and self-care of older individuals with diabetes who live in underserved communities. Information about self-care, informal care, and service utilization in urban (largely Latino, n = 695) and rural (mostly white, n = 819) Medicare beneficiaries with diabetes living in federally designated medically underserved areas was collected using computer-aided telephone interviews as part of the baseline assessment in the Informatics and Diabetes Education and Telemedicine (IDEATel) Project. Where items were comparable, service use was compared with that of a nationally representative group of Medicare beneficiaries with diabetes, using data from the Medical Expenditure Panel Survey. Compared to nationally representative groups, the underserved groups reported worse general health but similar health care service use, with the exception of home care. However, compared to the underserved rural group, the underserved, largely minority urban group, reported worse general health (P < 0.0001); more inpatient nights (P = 0.003), emergency room visits (P < 0.001), and home health care (P < 0.001); spent more time on self-care; and had more difficulty with housework, meal preparation, and personal care. Differences in service use between urban and rural groups within the underserved group substantially exceeded differences between the underserved and nationally representative groups. These findings address a gap in knowledge about older, ethnically diverse individuals with diabetes living in medically underserved areas. This profile of disparate service use and health care practices among urban minority and rural majority underserved adults with diabetes can assist in the planning of future interventions.

Patient cost-sharing and healthcare spending growth

In this paper, we explore the role patient incentives play in slowing healthcare spending growth. Evidence suggests that while patients do indeed respond to financial incentives, cost-sharing does not uniformly improve value; rather, cost-sharing provisions must be deliberately structured and targeted to reduce care of low marginal value. Other mechanisms may be helpful in targeting particular populations or types of utilization. The spillover effects between privately insured and publicly insured populations as well as market imperfections suggest a potential role for public policy in promoting insurance design that slows spending growth while increasing the health that each dollar buys.

Health care use and decision making among lower-income families in high-deductible health plans

BACKGROUND

Lower-income families may face unique challenges in high-deductible health plans (HDHPs).

METHODS

We administered a cross-sectional survey to a stratified random sample of families in a New England health plan's HDHP with at least $500 in annualized out-of-pocket expenditures. Lower-income families were defined as having incomes that were less than 300% of the federal poverty level. Primary outcomes were cost-related delayed or foregone care, difficulty understanding plans, unexpected costs, information-seeking, and likelihood of families asking their physician about hypothetical recommended services subject to the plan deductible. Multivariate logistic regression was used to control for potential confounders of associations between income group and primary outcomes.

RESULTS

Lower-income families (n = 141) were more likely than higher-income families (n = 273) to report cost-related delayed or foregone care (57% vs 42%; adjusted odds ratio [AOR], 1.81; 95% confidence interval [CI], 1.15-2.83]). There were no differences in plan understanding, unexpected costs, or information-seeking by income. Lower-income families were more likely than others to say they would ask their physician about a $100 blood test (79% vs 63%; AOR, 1.97; 95% CI, 1.18-3.28) or a $1000 screening colonoscopy (89% vs 80%; AOR, 2.04; 95% CI, 1.06-3.93) subject to the plan deductible.

CONCLUSIONS

Lower-income families with out-of-pocket expenditures in an HDHP were more likely than higher-income families to report cost-related delayed or foregone care but did not report more difficulty understanding or using their plans, and might be more likely to question services requiring out-of-pocket expenditures. Policymakers and physicians should consider focused monitoring and benefit design modifications to support lower-income families in HDHPs.

Simulation modeling of health care policy

Simulation modeling of health reform is a standard part of policy development and, in the United States, a required element in enacting health reform legislation. Modelers use three types of basic structures to build models of the health system: microsimulation, individual choice, and cell-based. These frameworks are filled in with data on baseline characteristics of the system and parameters describing individual behavior. Available data on baseline characteristics are imprecise, and estimates of key empirical parameters vary widely. A comparison of estimated and realized consequences of several health reform proposals suggests that models provided reasonably accurate estimates, with confidence bounds of approximately 30%.