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Moon KJ, Linton SL, Mojtabai R. Medical Debt and the Mental Health Treatment Gap Among US Adults. JAMA Psychiatry 2024:2821271. [PMID: 39018037 PMCID: PMC11255967 DOI: 10.1001/jamapsychiatry.2024.1861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/25/2024] [Indexed: 07/18/2024]
Abstract
Importance Medical debt is common in the US and may hinder timely access to care for mental disorders. Objective To estimate the prevalence of medical debt among US adults with depression and anxiety and its association with delayed and forgone mental health care. Design, Setting, and Participants Cross-sectional, nationally representative survey study of US adult participants in the 2022 National Health Interview Survey who had current or lifetime diagnoses of depression or anxiety. Exposures Self-reported lifetime clinical diagnoses of depression and anxiety; moderate to severe symptoms of current depression (Patient Health Questionnaire-8 score ≥10) and anxiety (Generalized Anxiety Disorder-7 score ≥10) irrespective of lifetime diagnoses; and past-year medical debt. Main Outcomes and Measures Self-reported delaying and forgoing mental health care because of cost in the past year. Results Among 27 651 adults (15 050 [54.4%] female; mean [SD] age, 52.9 [18.4] years), 5186 (18.2%) reported lifetime depression, 1948 (7.3%) reported current depression, 4834 (17.7%) reported lifetime anxiety, and 1689 (6.6%) reported current anxiety. Medical debt was more common among adults with lifetime depression (19.9% vs 8.6%; adjusted prevalence ratio [aPR], 1.97; 95% CI, 1.96-1.98), lifetime anxiety (19.4% vs 8.8%; aPR, 1.91; 95% CI, 1.91-1.92), current depression (27.3% vs 9.4%; aPR, 2.34; 95% CI, 2.34-2.36), and current anxiety (26.2% vs 9.6%; aPR, 2.24; 95% CI, 2.24-2.26) compared with adults without the respective mental disorders. Medical debt was associated with delayed health care among adults with lifetime depression (29.0% vs 11.6%; aPR, 2.68; 95% CI, 2.62-2.74), lifetime anxiety (28.0% vs 11.5%; aPR, 2.45; 95% CI, 2.40-2.50), current depression (36.9% vs 17.4%; aPR, 2.25; 95% CI, 2.13-2.38), and current anxiety (38.4% vs 16.9%; aPR, 2.48; 95% CI, 2.35-2.66) compared with those without these diagnoses. Medical debt was associated with forgone health care among adults with lifetime depression (29.4% vs 10.6%; aPR, 2.66; 95% CI, 2.61-2.71), lifetime anxiety (28.2% vs 10.7%; aPR, 2.63; 95% CI, 2.57-2.68), current depression (38.0% vs 17.2%; aPR, 2.35; 95% CI, 2.23-2.48), and current anxiety (40.8% vs 17.1%; aPR, 2.57; 95% CI, 2.43-2.75) compared with those without the diagnoses. Conclusions and Relevance Medical debt is prevalent among adults with depression and anxiety and may contribute to the mental health treatment gap. In the absence of structural reform, new policies are warranted to protect against this financial barrier to mental health care.
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Affiliation(s)
- Kyle J. Moon
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sabriya L. Linton
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Ramin Mojtabai
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Hubbard S. Education and Financial Knowledge in Health-Related Financial Decisions. HEALTH EDUCATION & BEHAVIOR 2024:10901981241227168. [PMID: 38258824 DOI: 10.1177/10901981241227168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
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.
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Affiliation(s)
- Sean Hubbard
- University of North Texas at Dallas, Dallas, TX, USA
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Lemon TL, Tassiopoulos K, Tsai AC, Cantos K, Escudero D, Quinn MK, Kacanek D, Berman C, Salomon L, Nichols S, Chadwick EG, Seage GR, Williams PL. Health Insurance Coverage, Clinical Outcomes, and Health-Related Quality of Life Among Youth Born to Women Living With HIV. J Acquir Immune Defic Syndr 2023; 92:6-16. [PMID: 36150048 PMCID: PMC9742193 DOI: 10.1097/qai.0000000000003100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2022] [Accepted: 07/25/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Although sustained access to health care is essential, little is known about the relationship between insurance coverage and health among people born to women living with HIV (WLHIV). SETTING Prospective cohort studies of youth and young adults born to WLHIV from 2007 to 2019. METHODS We used adjusted generalized estimating equation models to estimate mean differences in, and relative risks (RRs) of, health-related quality of life (HR-QoL) and HIV disease measures over time by insurance status. HR-QoL scales with limited variability were dichotomized. Modified Poisson models were used to estimate RRs. RESULTS Six hundred sixty-nine Adolescent Master Protocol (AMP) youth [66% living with perinatally-acquired HIV (PHIV), 72% Black] and 939 AMP Up/AMP Up Lite young adults (89% PHIV, 68% Black) reported insurance. Most were publicly insured (87% youth, 67% young adults). Privately insured young adults living with PHIV had lower risk of antiretroviral therapy nonadherence [adjusted RR (aRR): 0.82, 95% CI: 0.70 to 0.97] than those with public insurance. There was a lower risk of suboptimal role functioning for young adults with private insurance (aRR: 0.58, 95% CI: 0.35 to 0.97) and those unaware of their coverage (aRR: 0.41, 95% CI: 0.21 to 0.78). Young adults with private insurance had higher health perception scores than those with public insurance (adjusted mean difference: 3.87, 95% CI: 0.37 to 7.38). For youth, we observed no differences in HR-QOL and HIV disease measures by insurance. CONCLUSION These findings suggest meaningful differences in antiretroviral therapy adherence and some HR-QoL outcomes by health insurance coverage among young adults born to WLHIV.
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Affiliation(s)
- Tiffany L Lemon
- Center for Global Health, Massachusetts General Hospital, Boston, MA
| | | | - Alexander C Tsai
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Mongan Institute, Massachusetts General Hospital, Boston, MA
- Department of Psychiatry Harvard Medical School, Boston, MA
| | - Krystal Cantos
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- IQVIA Epidemiology & Drug Safety, Cambridge, MA
| | - Dan Escudero
- Center for Global Health, Massachusetts General Hospital, Boston, MA
| | - M K Quinn
- Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
| | - Deborah Kacanek
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Claire Berman
- Center for Global Health, Massachusetts General Hospital, Boston, MA
| | - Liz Salomon
- Center for Global Health, Massachusetts General Hospital, Boston, MA
| | - Sharon Nichols
- Department of Neurosciences, University of California, San Diego San Diego, CA; and
| | - Ellen G Chadwick
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - George R Seage
- Center for Global Health, Massachusetts General Hospital, Boston, MA
| | - Paige L Williams
- Center for Global Health, Massachusetts General Hospital, Boston, MA
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, MA
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Descriptive phenomenology study of the reasons for the low uptake of free health service package among type II diabetic patients. BMC Health Serv Res 2022; 22:1555. [PMID: 36539819 PMCID: PMC9764735 DOI: 10.1186/s12913-022-08953-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Although several diabetes management and control programs are introduced in Iran, rate of using such cares in patients with Type II Diabetic in Ahvaz is low and they show no tendency for receiving free diabetes service package. The aim of this study was to identify reasons behind low uptake of free health service package among T2DM patients in Ahvaz, Iran. METHODS This descriptive phenomenology study based on semi-structured guided interviews of patients with Type II Diabetic in Ahvaz, was carried out in the year 2021. Through purposeful sampling, 495 patients with diabetics who not received health services package more than 6 months were interviewed until the data saturation. The gathered data were analyzed through conventional content analysis. RESULTS Reasons were categorized into three themes which include 13 subthemes and 57 codes. Themes included individual, accessibility, and structural factors. Besides, subthemes were lack of awareness, poor health literacy, adverse patients experience, difficulties to use services, verbal miscommunication cultural barriers, low trust, geographic barriers, time barriers, financial difficulties, lack of human resources, poor service delivery, and organizational factors were as barriers to participation. CONCLUSION Regarding individual level, there is a need for further training of diabetic patients. Besides, for accessibility and structural factors Iranian healthcare system needs a comprehensive integrated care for the management of diabetes, this underlines the collaboration for improving patients' uptake of free health service package.
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Wu B, Cui Y, Jiang Y. The Role of Microfinance in China's Rural Public Health: Evidence from the Anti-Poverty Microcredit Program. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:10872. [PMID: 36078586 PMCID: PMC9518356 DOI: 10.3390/ijerph191710872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/27/2022] [Accepted: 08/28/2022] [Indexed: 06/15/2023]
Abstract
This study presents nonlinear evidence of the effects of a microcredit program implemented in poverty-stricken villages in China on rural public health using multivariate-ordered Probit and IV-ordered Probit models. The results, which were based on a unique set of data gathered from two rounds of official tracking statistics obtained through investigation (2015 and 2018) at a household level, suggest that rural residents' health levels and health insurance demands are related to the formal credit amount that they receive from the microcredit program. Further, the amount of debt that remains to be paid is a negative mediator and the poverty reduction degree is a positive mediator for the health impact of credit. After dividing the sample into subgroups according to income, credit rating and social network, the results show heterogeneity: the health outcomes of groups with a low income, a high credit rating and a strong social network are more significantly improved by loans. The estimations are still robust after using network and village clan numbers as instrumental variables to address endogeneity. Although most of the existing literature demonstrates that credit and indebtedness have negative impacts on health, our results supplement previous findings of the positive causality between access to formal credit and rural public health by showing that the former can exert positive effects by relaxing individuals' external constraints and increasing health spending.
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Affiliation(s)
- Benjian Wu
- School of Economics, Minzu University of China, Beijing 100081, China
| | - Yi Cui
- School of Economics, Beijing Technology and Business University, Beijing 100048, China
| | - Yushuo Jiang
- School of Economics, Minzu University of China, Beijing 100081, China
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Newlon JL, Bentley JP, Snyder ME, Zillich AJ, Rafie S, Illingworth Plake KS. Impact of pharmacist prescribing through direct pharmacy access policies on access to hormonal contraception. J Am Pharm Assoc (2003) 2021; 62:194-201.e1. [PMID: 34454867 DOI: 10.1016/j.japh.2021.08.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND/OBJECTIVE This study assesses the impact of direct pharmacy access (DPA) policies that allow pharmacists to prescribe hormonal contraceptives on women's access by comparing access among 3 groups: (1) women in a state without DPA (Indiana), (2) women in a state with DPA, but not using DPA, and (3) women in a state with DPA and using DPA. METHODS This cross-sectional survey, including a scale to measure access to contraceptives, perception items, and demographics, was distributed through Amazon Mechanical Turk (Amazon.com, Inc). Kruskal-Wallis tests and linear regression analysis were used. RESULTS The sample size was 316. When controlling for education, income, and age, the women not using DPA (in Indiana and a DPA state, respectively) reported significantly higher levels of approachability (P < 0.001 and P < 0.001, respectively), acceptability (P < 0.001 and P < 0.001, respectively), availability and accommodation (P < 0.001 and P = 0.009, respectively), affordability (P < 0.001 and P < 0.001, respectively), and appropriateness (P < 0.001 and P < 0.001) access than the women using DPA. The women using DPA reported significantly lower levels of privacy access than those not using DPA in a DPA state (P = 0.004) when controlling for education, income, and age. However, 78.9% of women using DPA agreed DPA made obtaining contraceptives easier. Most of the women who had never used DPA were previously unaware of DPA (81.1% in DPA states and 86.2% in Indiana) but felt that it would improve access (82.8% and 80.0%, respectively). CONCLUSION Understanding the effects of DPA policies on women's access to contraceptives can inform future policies and support implementation. Lower levels of access across all dimensions among those using DPA may be influenced by imperfect implementation and failure to legislatively enable the sustainability of this service rather than pharmacists' ability to improve women's access.
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Tabler J, Mykyta L. Forgoing Care in Southernmost Texas: Compounding Hardship and Health Among Latinx Immigrant Border Residents. FAMILY & COMMUNITY HEALTH 2021; 44:171-183. [PMID: 32841999 DOI: 10.1097/fch.0000000000000269] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
This study examines how material hardship and perceived discrimination are associated with health care access and self-rated health among lower Rio Grande Valley residents. Of respondents to surveys administered at 2 clinic systems (N = 546), approximately 67% reported forgoing medical care in the past 12 months. Regression results suggested that perceived discrimination (odds ratio [OR] = 1.05, P < .05) and material hardship (OR = 1.63, P < .001) increased the odds of forgoing care. Also, discrimination (OR = 1.04, P < .01) and material hardship (OR = 1.24, P < .001) were independently associated with worse self-rated health. Service providers should consider screening for hardship experiences to target resources to address these stressors on patient health.
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Affiliation(s)
- Jennifer Tabler
- Department of Criminal Justice and Sociology, University of Wyoming, Laramie (Dr Tabler); and Department of Sociology and Anthropology, The University of Texas Rio Grande Valley, Edinburg (Dr Mykyta)
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Warth J, Beckmann N, Puth MT, Tillmann J, Porz J, Zier U, Weckbecker K, Weltermann B, Münster E. Association between over-indebtedness and antidepressant use: A cross-sectional analysis. PLoS One 2020; 15:e0236393. [PMID: 32706806 PMCID: PMC7380887 DOI: 10.1371/journal.pone.0236393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Accepted: 07/06/2020] [Indexed: 11/27/2022] Open
Abstract
Background Burden of disease caused by depression and its association with socioeconomic status is well documented. However, research on over-indebtedness is scarce although millions of European citizens in all socioeconomic positions are over-indebted. Prior studies suggested that over-indebtedness is associated with poor physical and mental health. Aims Investigate the association between over-indebtedness and antidepressant use in Germany. Method A cross-sectional survey among debt advice agencies’ clients was conducted in North Rhine-Westphalia, Germany, in 2017 (OID). Data were merged with the first wave of the German Health Interview and Examination Survey for Adults (DEGS1). Descriptive statistics and logistic regression analysis were used to examine antidepressant use in the previous 7 days (OID: n = 699; DEGS1: n = 7115). Results Prevalence of antidepressant use was higher in the over-indebted (12.3%) than the general population (5.0%). The over-indebted were significantly more likely to use antidepressants than the general population even after controlling for other socioeconomic, demographic and health factors (adjusted odds ratio 1.83; 95% confidence interval 1.35–2.48). Conclusions Stakeholders in health care, debt counselling, research and social policy should consider the link between over-indebtedness and mental illness to advance the understanding of health inequalities and to help those who have mental health and debt problems.
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Affiliation(s)
- Jacqueline Warth
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
- * E-mail:
| | - Niklas Beckmann
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Marie-Therese Puth
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
- Department of Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Bonn, Germany
| | - Judith Tillmann
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Johannes Porz
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Ulrike Zier
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
- Faculty of Health/ Department of Medicine, Institute for General Medicine and Interprofessional Care, University Witten/Herdecke, Herdecke, Germany
| | - Birgitta Weltermann
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Eva Münster
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
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Proposal for smoke-free public housing: a systematic review of attitudes and preferences from residents of multi-unit housing. J Public Health Policy 2020; 41:496-514. [PMID: 32620837 DOI: 10.1057/s41271-020-00236-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A policy proposal to ban public housing smoking indoors has received support, but it is unclear how certain affected groups, specifically smokers in housing units, perceive such a policy. To review the literature on attitudes and perceptions of housing unit tenants towards an indoor smoke-free housing policy, using various databases, we searched articles for attitudes towards smoking ban enforcement in housing units. We identified fourteen articles. Non-smokers heavily favored indoor policies and current smokers heavily opposed them. Current smokers represented a substantial minority in the reviewed articles, resulting in overall outcomes of the surveys driven by non-smokers. Studies investigating attitudes about housing smoking bans largely represent the views of non-smokers and lack data about barriers and concerns of tenants who do not support a smoke-free policy. Future studies should investigate if such a discrepancy impacts the efficacy of smoke-free housing policies.
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Li J, Jiao C, Nicholas S, Wang J, Chen G, Chang J. Impact of Medical Debt on the Financial Welfare of Middle- and Low-Income Families across China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17124597. [PMID: 32604840 PMCID: PMC7344870 DOI: 10.3390/ijerph17124597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Revised: 05/10/2020] [Accepted: 06/15/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Medical debt is a persistent global issue and a crucial and effective indicator of long-term family medical financial burden. This paper fills a research gap on the incidence and causes of medical debt in Chinese low- and middle-income households. METHOD Data were obtained from the 2015 China Household Finance Survey, with medical debt measured as borrowings from families, friends and third parties. Tobit regression models were used to analyze the data. The concentration index was employed to measure the extent of socioeconomic inequality in medical debt incidence. RESULTS We found that 2.42% of middle-income families had medical debt, averaging US$6278.25, or 0.56 times average household yearly income and 3.92% of low-income families had medical debts averaging US$5419.88, which was equivalent to 2.49 times average household yearly income. The concentration index for low and middle-income families' medical debt was significantly pro-poor. Medical debt impoverished about 10% of all non-poverty households and pushed poverty households deeper into poverty. While catastrophic health expenditure (CHE) was the single most important factor in medical debt, age, education, and health status of householder, hospitalization and types of medical insurance were also significant factors determining medical debt. CONCLUSIONS Using a narrow definition of medical debt, the incidence of medical debt in Chinese low- and middle-income households was relatively low. But, once medical debt happened, it imposed a long-term financial burden on medical indebted families, tipping many low and middle-income households into poverty and imposing on households several years of debt repayments. Further studies need to use broader definitions of medical debt to better assess the long-term financial impact of medical debt on Chinese families. Policy makers need to modify China's basic medical insurance schemes to manage out-of-pocket, medical debt and CHE and to take account of pre-existing medical debt.
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Affiliation(s)
- Jiajing Li
- Center for Health Economics Experiment and Public Policy, School of Public Health, Cheeloo College of Medicine, Shandong University, No. 44 Wenhua West Road, Lixia District, Jinan 250012, China; (J.L.); (C.J.)
| | - Chen Jiao
- Center for Health Economics Experiment and Public Policy, School of Public Health, Cheeloo College of Medicine, Shandong University, No. 44 Wenhua West Road, Lixia District, Jinan 250012, China; (J.L.); (C.J.)
| | - Stephen Nicholas
- School of Economics and School of Management, Tianjin Normal University, No. 339 Binshui West Avenue, Tianjin 300387, China;
- Guangdong Institute for International Strategies, Guangdong University of Foreign Studies, 2 Baiyun North Avenue, Guangzhou, Guangdong 510420, China
- Top Education Institute, 1 Central Avenue, Australian Technology Park, Eveleigh, Sydney, NSW 2015, Australia
- Newcastle Business School, University of Newcastle, University Drive, Newcastle, NSW 2308, Australia
| | - Jian Wang
- Dong Fureng Institute of Economics and Social Development, Wuhan University, No. 54 Dongsi Lishi Hutong, Dongcheng District, Beijing 100010, China;
- Center for Health Economics and Management, Economics and Management School, Wuhan University, Luojia Hill, Wuhan 430072, China
| | - Gong Chen
- Institute of Population Research, Peking University, No. 5 Yiheyuan Road, Haidian District, Beijing 100871, China;
| | - Jinghua Chang
- Institute of Population Research, Peking University, No. 5 Yiheyuan Road, Haidian District, Beijing 100871, China;
- Correspondence:
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Bielenberg JE, Futrell M, Stover B, Hagopian A. Presence of Any Medical Debt Associated With Two Additional Years of Homelessness in a Seattle Sample. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020923535. [PMID: 32513034 PMCID: PMC7285940 DOI: 10.1177/0046958020923535] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Although medical debt has been associated with housing instability, almost no research has connected homelessness to medical debt. We interviewed 60 individuals experiencing homelessness in Seattle, selected from those participating in self-governed encampments organized by a homeless advocacy organization. Most respondents reported having at least one kind of debt, with two-thirds reporting current medical debt. Almost half reported trouble paying medical bills for themselves or family members. Almost one-third believed medical debt was in part responsible for their current housing situation. More than half with medical debt incurred this debt while they were covered under insurance. People who had trouble paying medical bills experienced a more recent episode of homelessness 2 years longer than those who did not have such trouble, even after controlling for race, education, age, gender, and health status. People of color who had trouble paying medical bills reported almost 1 year more homelessness than whites.
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Affiliation(s)
| | - Marvin Futrell
- School of Public Health, University of Washington, Seattle, USA
| | - Bert Stover
- School of Public Health, University of Washington, Seattle, USA
| | - Amy Hagopian
- School of Public Health, University of Washington, Seattle, USA
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Warth J, Puth MT, Zier U, Beckmann N, Porz J, Tillmann J, Weckbecker K, Bosma H, Weltermann B, Münster E. Patient-physician communication about financial problems: A cross-sectional study among over-indebted individuals. PLoS One 2020; 15:e0232716. [PMID: 32369528 PMCID: PMC7199951 DOI: 10.1371/journal.pone.0232716] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/20/2020] [Indexed: 11/19/2022] Open
Abstract
Background About every tenth household across Europe is unable to meet payment obligations and living expenses on an ongoing basis and is thus considered over-indebted. Previous research suggests that over-indebtedness reflects a potential cause and consequence of psychosomatic health problems and limited access to care. However, it is unclear whether those affected discuss their financial problems with general practitioners. Therefore, this study examined patient-physician communication about financial problems in general practice among over-indebted individuals. Methods We conducted a cross-sectional survey among clients of 70 debt advice agencies in North Rhine-Westphalia, Germany, in 2017. We assessed the prevalence of patient-physician communication about financial problems and its association with patient characteristics using descriptive statistics and logistic regression analysis. Of 699 individuals who returned the questionnaire (response rate:50.2%), we included 598 respondents enrolled in statutory health insurance with complete outcome data in the analyses. Results Conversations about financial problems with general practitioners were reported by 22.6% (n = 135) of respondents. Individuals with a high educational level were less likely to report such conversations than those with medium educational level (aOR 0.11; 95%CI 0.01–0.83) after adjustment for other sociodemographic characteristics, health status and measures of financial distress. Those without a migrant background(aOR 2.09; 95%CI 1.32–3.32), the chronically ill(aOR 1.90; 95%CI 1.16–3.13) and individuals who reported high financial distress(aOR 2.15; 95%CI 1.22–3.78) and cutting on necessities to pay for medications(aOR 1.86; 95%CI 1.12–3.09) were more likely to discuss financial problems than their counterparts. Conclusions Few over-indebted individuals discussed financial problems with their general practitioner. Patients’ health status, coping strategies and perception of financial distress might contribute to variations in disclosure of financial problems. Thus, enhancing communication and screening by routine assessment of financial problems in clinical practice can help to identify vulnerable patients and promote access to health care and social services and well-being for all.
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Affiliation(s)
- Jacqueline Warth
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
- * E-mail:
| | - Marie-Therese Puth
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
- Institute for Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital Bonn, Bonn, Germany
| | - Ulrike Zier
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Niklas Beckmann
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Johannes Porz
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Judith Tillmann
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
- Institute of General Practice, Medical Faculty of the Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Hans Bosma
- Department of Social Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Faculty of Health, Medicine and Life Sciences, Maastricht, The Netherlands
| | - Birgitta Weltermann
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
| | - Eva Münster
- Institute of General Practice and Family Medicine, University of Bonn, Bonn, Germany
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13
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Warth J, Puth MT, Tillmann J, Beckmann N, Porz J, Zier U, Weckbecker K, Weltermann B, Münster E. Cost-related medication nonadherence among over-indebted individuals enrolled in statutory health insurance in Germany: a cross-sectional population study. BMC Health Serv Res 2019; 19:887. [PMID: 31771583 PMCID: PMC6880370 DOI: 10.1186/s12913-019-4710-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/05/2019] [Indexed: 11/26/2022] Open
Abstract
Background Millions of citizens in high-income countries face over-indebtedness that implies being unable to cover payment obligations with available income and assets on an ongoing basis. Studies have shown an association between over-indebtedness and health outcomes, independent of standard socioeconomic status measures. Patterns of cost-related medication nonadherence (CRN) among over-indebted individuals are yet unclear. The aim of this study was to examine the frequency of nonadherence to prescribed medications due to cost, and to identify risk factors for CRN among over-indebted individuals in Germany. Methods In 2017, we conducted a cross-sectional survey among over-indebted individuals recruited in 70 debt advice agencies in North Rhine-Westphalia, Germany. Data on CRN in the last 12 months (i.e. not filling prescriptions, skipping or decreasing doses of prescribed medication due to financial problems) were collected by a survey using a self-administered written questionnaire that was returned by 699 individuals with a response rate of 50.2%. Prevalence of CRN was assessed using descriptive statistics. Multiple logistic regression analysis was performed to examine risk factors of CRN, including participants enrolled in statutory health insurance with complete data (n = 521). Results The prevalence of CRN was 33.6%. The chronically ill had significantly greater odds of cost-related medication nonadherence (aOR 1.96; 95% CI 1.27–3.03) than individuals without a chronic illness. CRN was more likely to occur in individuals who had discussed financial problems with their general practitioner (aOR 1.58; 95% CI 1.01–2.47). There was no association between CRN and other sociodemographic factors or socioeconomic status. Conclusions Medication nonadherence due to financial pressures is common among over-indebted citizens enrolled in statutory health insurance in Germany. Stakeholders in social policy, research and health care need to address over-indebtedness to develop strategies to safeguard access to relevant medications, especially among those with high morbidity. Trial registration Arzneimittelkonsum, insbesondere Selbstmedikation bei überschuldeten Bürgerinnen und Bürgern in Nordrhein-Westfalen (ArSemü), (engl. ‘Medication use, particularly self-medication among over-indebted citizens in North Rhine-Westphalia’), German Clinical Trials Register: DRKS00013100. Date of registration: 23.10.2017. Date of enrolment of the first participant: 18.07.2017, retrospectively registered.
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Affiliation(s)
- Jacqueline Warth
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Marie-Therese Puth
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Department of Medical Biometry, Informatics and Epidemiology (IMBIE), University Hospital of Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Judith Tillmann
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Niklas Beckmann
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johannes Porz
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Ulrike Zier
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Klaus Weckbecker
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.,Faculty of Medicine, Institute of General Practice, University of Düsseldorf, Düsseldorf University Hospital, Postfach 10 10 07, 40001, Düsseldorf, Germany
| | - Birgitta Weltermann
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Eva Münster
- Institute of General Practice and Family Medicine, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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14
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Panczak R, von Wyl V, Reich O, Luta X, Maessen M, Stuck AE, Berlin C, Schmidlin K, Goodman DC, Egger M, Clough-Gorr K, Zwahlen M. Death at no cost? Persons with no health insurance claims in the last year of life in Switzerland. BMC Health Serv Res 2018. [PMID: 29540161 PMCID: PMC5853076 DOI: 10.1186/s12913-018-2984-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Lack of health insurance claims (HIC) in the last year of life might indicate suboptimal end-of-life care, but reasons for no HIC are not fully understood because information on causes of death is often missing. We investigated association of no HIC with characteristics of individuals and their place of residence. Methods We analysed HIC of persons who died between 2008 and 2010, which were obtained from six providers of mandatory Swiss health insurance. We probabilistically linked these persons to death certificates to get cause of death information and analysed data using sex-stratified, multivariable logistic regression. Supplementary analyses looked at selected subgroups of persons according to the primary cause of death. Results The study population included 113,277 persons (46% males). Among these persons, 1199 (proportion 0.022, 95% CI: 0.021–0.024) males and 803 (0.013, 95% CI: 0.012–0.014) females had no HIC during the last year of life. We found sociodemographic and health differentials in the lack of HIC at the last year of life among these 2002 persons. The likelihood of having no HIC decreased steeply with older age. Those who died of cancer were more likely to have HIC (adjusted odds ratio for males 0.17, 95% CI: 0.13–0.22; females 0.19, 95% CI: 0.12–0.28) whereas those dying of mental and behavioural disorders (AOR males 1.83, 95% CI:1.42–2.37; females 1.65, 95% CI: 1.27–2.14), and males dying of suicide (AOR 2.15, 95% CI: 1.72–2.69) and accidents (AOR 2.41, 95% CI: 1.96–2.97) were more likely to have none. Single, widowed, and divorced persons also were more likely to have no HIC (AORs in range of 1.29–1.80). There was little or no association between the lack of HIC and characteristics of region of residence. Patterns of no HIC differed across main causes of death. Associations with age and civil status differed in particular for persons who died of cancer, suicide, accidents and assaults, and mental and behavioural disorders. Conclusions Particular groups might be more likely to not seek care or not report health insurance costs to insurers. Researchers should be aware of this aspect of health insurance data and account for persons who lack HIC. Electronic supplementary material The online version of this article (10.1186/s12913-018-2984-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Radoslaw Panczak
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland.
| | - Viktor von Wyl
- Epidemiology, Biostatistics & Prevention Institute, University of Zürich, Hirschengraben 84, 8001, Zurich, Switzerland
| | - Oliver Reich
- Department of Health Sciences, Helsana Insurance Group, Palmstrasse 26b, 8401, Winterthur, Switzerland.,SWICA Gesunheitsorganisation, sante24, Winterthur, Switzerland
| | - Xhyljeta Luta
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Maud Maessen
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland.,University Center for Palliative Care, Inselspital, Bern University Hospital, University of Bern, Freiburgstrasse 28, 3010, Bern, Switzerland
| | - Andreas E Stuck
- Department of Geriatrics, Inselspital, Bern University Hospital, and University of Bern, Freiburgstrasse, 3010, Bern, Switzerland
| | - Claudia Berlin
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Kurt Schmidlin
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - David C Goodman
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland.,The Dartmouth Institute of Health Policy & Clinical Practice, Lebanon, NH, USA
| | - Matthias Egger
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
| | - Kerri Clough-Gorr
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland.,Section of Geriatrics, Boston University Medical Center, Boston, MA, USA
| | - Marcel Zwahlen
- Institute of Social and Preventive Medicine, University of Bern, Finkenhubelweg 11, 3012, Bern, Switzerland
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15
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Choi S. Experiencing Financial Hardship Associated With Medical Bills and Its Effects on Health Care Behavior: A 2-Year Panel Study. HEALTH EDUCATION & BEHAVIOR 2017; 45:616-624. [DOI: 10.1177/1090198117739671] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Using 2-year panel data, this study examined (1) whether experiencing financial hardship associated with out-of-pocket medical expenditures affected delaying/missing necessary health care in the following year; (2) whether such financial hardship mediated the effects of predisposing, enabling, and need characteristics on timely health care access (i.e., significant indirect effects); and (3)whether such mediating effects are different by chronic health status (i.e., moderated mediation) among U.S. adults. The 2011 National Health Interview Survey was linked to the 2012 Medical Expenditure Panel Survey. The sample includes 8,993 adults aged between 26 and 64 years. Among them, 1,089 reported having at least one chronic health condition that had caused activity limitations. Multiple-group path analysis was conducted using Mplus 7.2. Approximately 35% experienced financial difficulties paying medical bills, including 28% who were currently paying off medical debts. Almost 14% of the respondents reported delayed/missed necessary medical treatments. In addition to direct effects, predisposing, enabling, and need factors affected access to care indirectly via financial hardship, although significant moderated mediation was found by chronic health status. However, different from the Andersen’s behavioral model of health service utilization, the effect of financial hardship due to medical bills as a barrier to the timely use of necessary health services was not smaller among adults with chronic health conditions. Policy alternatives should be explored to provide affordable financing programs and adequate safety net health services to reduce the financial burden of health care for those who are financially vulnerable, especially those suffering from chronic health conditions.
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Affiliation(s)
- Sunha Choi
- The University of Tennessee, Knoxville, TN, USA
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16
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Ellis RP, Bachman SS, Tan HR. Refining Our Understanding of Value-Based Insurance Design and High Cost Sharing on Children. Pediatrics 2017; 139:S136-S144. [PMID: 28562311 DOI: 10.1542/peds.2016-2786h] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/12/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND There is significant concern about the financial burdens of new insurance plan designs on families, particularly families with children and youth with special health care needs (CYSHCN). With value-based insurance design (VBID) plans growing in popularity, this study examined the implications of selected VBID cost-sharing features on children. METHODS We studied children's health care spending patterns in 2 data sets that include high deductible and narrow network plans among others. Medical Expenditure Panel Survey data from 2007 to 2013 on 22 392 children were used to study out-of-pocket (OOP) costs according to CYSHCN, family income, and spending. MarketScan large employer insurance claims data from 2007 to 2014 (N = 4 263 452) were used to test for differences in mean total payments and OOP costs across various health plans. RESULTS Across the data sets, we found that existing health plans place significant financial burdens on families, particularly lower income households and families with CYSHCN; individuals among the top 10% of OOP spending averaged more than $2000 per child. Although high deductible and consumer-driven plans impose substantial OOP costs on children, they do not significantly reduce spending, whereas health maintenance organizations that use network restrictions and tighter management do. CONCLUSIONS Our results do not support the conclusion that high cost-sharing features that are common in VBID plans will significantly reduce health care spending on children.
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Affiliation(s)
| | - Sara S Bachman
- Schools of Social Work and Public Health, Boston University, Boston, Massachusetts
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17
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Henrikson NB, Chang E, Ulrich K, King D, Anderson ML. Communication with Physicians about Health Care Costs: Survey of an Insured Population. Perm J 2017; 21:16-070. [PMID: 28406786 PMCID: PMC5391781 DOI: 10.7812/tpp/16-070] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
CONTEXT Health care costs have increasingly shifted to patients, and financial distress caused by medical care has increased. Patients may wish to discuss costs with their clinicians. OBJECTIVE Describe patient preferences for communication about cost in the clinical setting. DESIGN Cross-sectional, self-administered survey of a stratified random sample of the population insured in an integrated health care system in Washington State. Our sampling frame was the entire membership aged 21 years or older. Sampling was stratified by sex and group practice enrollment. MAIN OUTCOME MEASURES Preference for discussing health care costs with one's physician. We conducted regression analyses to determine predictors of communication preference; potential predictors included demographic characteristics, financial burden, delay in seeking care because of cost, and socioeconomic variables. Survey responses were weighted to adjust for nonresponse and sampling. RESULTS Of 7200 invitations sent, 2200 survey responses were returned. Ninety-two percent wished to know their out-of-pocket costs before beginning treatment. Most respondents preferred their physician talk with them about out-of-pocket costs (81.4%) and expressed comfort with discussing costs with their physician (75.6%). Overall, 43.7% reported any delay in seeking care in the previous 12 months. One in 5 respondents (21.6%) reported family medical debt. Delay in seeking care was positively and independently associated with preferring to discuss costs with one's physician; current medical financial burden was not. CONCLUSION Patient preferences for communication about costs with physicians are high, and medical debt and delay in care-seeking are prevalent. Delay in care-seeking independently predicts cost communication preferences.
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Affiliation(s)
- Nora B Henrikson
- Research Associate at Kaiser Permanente Washington Health Research Institute, formerly Group Health Research Institute, in Seattle, WA.
| | - Eva Chang
- Research Public Health Analyst from the Division of Health Services and Social Policy at RTI International in Waltham, MA.
| | - Kevin Ulrich
- Director of the Survey Lab Research Center from the Division of the Social Sciences at the University of Chicago in IL.
| | - Deborah King
- Research Interventionist at Kaiser Permanente Washington Health Research Institute, formerly Group Health Research Institute, in Seattle, WA.
| | - Melissa L Anderson
- Senior Biostatistician at Kaiser Permanente Washington Health Research Institute, formerly Group Health Research Institute, in Seattle, WA.
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18
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Martin-Carrasco M, Evans-Lacko S, Dom G, Christodoulou NG, Samochowiec J, González-Fraile E, Bienkowski P, Gómez-Beneyto M, Dos Santos MJH, Wasserman D. EPA guidance on mental health and economic crises in Europe. Eur Arch Psychiatry Clin Neurosci 2016; 266:89-124. [PMID: 26874960 DOI: 10.1007/s00406-016-0681-x] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 01/28/2016] [Indexed: 12/16/2022]
Abstract
This European Psychiatric Association (EPA) guidance paper is a result of the Working Group on Mental Health Consequences of Economic Crises of the EPA Council of National Psychiatric Associations. Its purpose is to identify the impact on mental health in Europe of the economic downturn and the measures that may be taken to respond to it. We performed a review of the existing literature that yields 350 articles on which our conclusions and recommendations are based. Evidence-based tables and recommendations were developed through an expert consensus process. Literature dealing with the consequences of economic turmoil on the health and health behaviours of the population is heterogeneous, and the results are not completely unequivocal. However, there is a broad consensus about the deleterious consequences of economic crises on mental health, particularly on psychological well-being, depression, anxiety disorders, insomnia, alcohol abuse, and suicidal behaviour. Unemployment, indebtedness, precarious working conditions, inequalities, lack of social connectedness, and housing instability emerge as main risk factors. Men at working age could be particularly at risk, together with previous low SES or stigmatized populations. Generalized austerity measures and poor developed welfare systems trend to increase the harmful effects of economic crises on mental health. Although many articles suggest limitations of existing research and provide suggestions for future research, there is relatively little discussion of policy approaches to address the negative impact of economic crises on mental health. The few studies that addressed policy questions suggested that the development of social protection programs such as active labour programs, social support systems, protection for housing instability, and better access to mental health care, particularly at primary care level, is strongly needed.
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Affiliation(s)
- M Martin-Carrasco
- Institute of Psychiatric Research, Mª Josefa Recio Foundation (Hospitaller Sisters), Bilbao, Spain. .,Centro de Investigación en Red Salud Mental (CIBERSAM), Madrid, Spain. .,Clinica Padre Menni, Department of Psychiatry, Joaquin Beunza, 45, 31014, Pamplona, Spain.
| | - S Evans-Lacko
- Health Service and Population Research Department, Institute of Psychiatry, King's College London, De Crespigny Park, London, UK.,PSSRU, London School of Economics and Political Science, Houghton Street, London, WC2A 2AE, UK
| | - G Dom
- Collaborative Antwerp Psychiatric Research Institute, Antwerp University, 2610, Wilrijk, Belgium
| | | | - J Samochowiec
- Department of Psychiatry, Pomeranian Medical University, Szczecin, Poland
| | - E González-Fraile
- Institute of Psychiatric Research, Mª Josefa Recio Foundation (Hospitaller Sisters), Bilbao, Spain
| | - P Bienkowski
- Department of Pharmacology, Institute of Psychiatry and Neurology, Warsaw, Poland
| | - M Gómez-Beneyto
- Centro de Investigación en Red Salud Mental (CIBERSAM), Madrid, Spain.,University of Valencia, Valencia, Spain
| | - M J H Dos Santos
- Portuguese Society of Psychiatry and Mental Health, Beatriz Ângelo Hospital, Lisbon, Portugal
| | - D Wasserman
- National Centre for Suicide Research and Prevention of Mental Health, Karolinska Institute, Stockholm, Sweden
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19
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Valid Psychological Injury Claims: Respecting the Needs of Survivors. PSYCHOLOGICAL INJURY & LAW 2015. [DOI: 10.1007/s12207-015-9234-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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20
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Abstract
Local or small-area estimates to capture emerging trends across large geographic regions are critical in identifying and addressing community-level health interventions. However, they are often unavailable due to lack of analytic capabilities in compiling and integrating extensive datasets and complementing them with the knowledge about variations in state-level health policies. This study introduces a modeling approach for small-area estimation of spatial access to pediatric primary care that is data "rich" and mathematically rigorous, integrating data and health policy in a systematic way. We illustrate the sensitivity of the model to policy decision making across large geographic regions by performing a systematic comparison of the estimates at the census tract and county levels for Georgia and California. Our results show the proposed approach is able to overcome limitations of other existing models by capturing patient and provider preferences and by incorporating possible changes in health policies. The primary finding is systematic underestimation of spatial access, and inaccurate estimates of disparities across population and across geography at the county level with respect to those at the census tract level with implications on where to focus and which type of interventions to consider.
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21
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Baughman KR, Burke RC, Hewit MS, Sudano JJ, Meeker J, Hull SK. Associations between Difficulty Paying Medical Bills and Forgone Medical and Prescription Drug Care. Popul Health Manag 2015; 18:358-66. [DOI: 10.1089/pop.2014.0128] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Kristin R. Baughman
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Ryan C. Burke
- College of Public Health, Kent State University, Kent, Ohio
| | - Michael S. Hewit
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Joseph J. Sudano
- Epidmiology and Biostatistics, Case Western Reserve University School of Medicine, Center for Health Care Research and Policy, Case Western Reserve University and The MetroHealth System, Cleveland, Ohio
| | - James Meeker
- Department of Family and Community Medicine, Northeast Ohio Medical University, Rootstown, Ohio
| | - Sharon K. Hull
- Department of Community and Family Medicine, Duke University School of Medicine, Durham, North Carolina
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22
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Bachman SS, Comeau M, Dworetzky B, Hamershock R, Hirschi M. The Louisiana Family Opportunity Act Medicaid Buy-in Program. Matern Child Health J 2015; 19:2568-77. [PMID: 26169811 DOI: 10.1007/s10995-015-1775-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The Family Opportunity Act Medicaid Buy-In Program (FOA) allows states to expand Medicaid coverage to children who meet selected disability and income eligibility criteria. FOA programs may help address family financial hardship as a result of underinsurance. We provide specific information about the FOA program and report the first results of a survey of parents or guardians of children with disabilities who were enrolled in Louisiana's FOA program. METHODS A convenience sample of families enrolled in the program (N = 52) responded to questions derived from the National Survey of Children with Special Health Care Needs (CSHCN). These results were compared to two groups of Louisiana families of CSHCN that had responded to the 2009/10 national survey. RESULTS Data suggest that children enrolled in the Louisiana FOA are younger than those enrolled in Supplemental Security Income, are more likely to have functional losses, and, perhaps due to their age, are less likely to have difficulty with anxiety, depression, or behavior problems. FOA families are less likely than families in either group to report receiving help with care coordination, and more likely to report financial problems due to their child's health. Respondents were also more likely to report that they received all the therapy services and specialty care they needed. CONCLUSIONS The FOA program thus appears to be filling a niche in coverage needs among families of children with disabilities in Louisiana.
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Affiliation(s)
- Sara S Bachman
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA.
| | - Meg Comeau
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Beth Dworetzky
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Rose Hamershock
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
| | - Melissa Hirschi
- Health and Disability Working Group, Boston University School of Public Health, 715 Albany Street, Boston, MA, 02118, USA
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23
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Angier H, Gregg J, Gold R, Crawford C, Davis M, DeVoe JE. Understanding how low-income families prioritize elements of health care access for their children via the optimal care model. BMC Health Serv Res 2014; 14:585. [PMID: 25406509 PMCID: PMC4240836 DOI: 10.1186/s12913-014-0585-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 11/07/2014] [Indexed: 11/22/2022] Open
Abstract
Background Insurance coverage alone does not guarantee access to needed health care. Few studies have explored what “access” means to low-income families, nor have they examined how elements of access are prioritized when availability, affordability, and acceptability are not all achievable. Therefore, we explored low-income parents’ perspectives on accessing health care. Methods In-depth interviews with a purposeful sample of 29 Oregon parents who responded to a previously administered statewide survey about health insurance. Transcribed interviews were analyzed by a multidisciplinary team using a standard iterative process. Results Parents highlighted affordability and limited availability as barriers to care; a continuous relationship with a health care provider helped them overcome these barriers. Parents also described the difficult decisions they made between affordability and acceptability in order to get the best care they could for their children. We present a new conceptual model to explain these experiences accessing care with health insurance: the Optimal Care Model. The model shows a transition from optimal care to a breaking point where affordability becomes the driving factor, but the care is perceived as unacceptable because it is with an unknown provider. Conclusions Even when covered by health insurance, low-income parents face barriers to accessing health care for their children. As the Affordable Care Act and other policies increase coverage options across the United States, many Americans may experience similar barriers and facilitators to health care access. The Optimal Care Model provides a useful construct for better understanding experiences that may be encountered when the newly insured attempt to access available, acceptable, and affordable health care services.
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Wisk LE, Gangnon R, Vanness DJ, Galbraith AA, Mullahy J, Witt WP. Development of a novel, objective measure of health care-related financial burden for U.S. families with children. Health Serv Res 2014; 49:1852-74. [PMID: 25328073 DOI: 10.1111/1475-6773.12248] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To develop and validate a theoretically based and empirically driven objective measure of financial burden for U.S. families with children. DATA SOURCES The measure was developed using 149,021 families with children from the National Health Interview Survey, and it was validated using 18,488 families with children from the Medical Expenditure Panel Survey. STUDY DESIGN We estimated the marginal probability of unmet health care need due to cost using a bivariate tensor product spline for family income and out-of-pocket health care costs (OOPC; e.g., deductibles, copayments), while adjusting for confounders. Recursive partitioning was performed on these probabilities, as a function of income and OOPC, to establish thresholds demarcating levels of predicted risk. PRINCIPAL FINDINGS We successfully generated a novel measure of financial burden with four categories that were associated with unmet need (vs. low burden: midlow OR: 1.93, 95 percent CI: 1.78-2.09; midhigh OR: 2.78, 95 percent CI: 2.49-3.10; high OR: 4.38, 95 percent CI: 3.99-4.80). The novel burden measure demonstrated significantly better model fit and less underestimation of financial burden compared to an existing measure (OOPC/income ≥ 10 percent). CONCLUSION The newly developed measure of financial burden establishes thresholds based on different combinations of family income and OOPC that can be applied in future studies of health care utilization and expenditures and in policy development and evaluation.
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Affiliation(s)
- Lauren E Wisk
- Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; Department of Population Health Sciences, School of Medicine and Public Health University of Wisconsin, Madison, Madison, WI
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25
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Turunen E, Hiilamo H. Health effects of indebtedness: a systematic review. BMC Public Health 2014; 14:489. [PMID: 24885280 PMCID: PMC4060868 DOI: 10.1186/1471-2458-14-489] [Citation(s) in RCA: 92] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2013] [Accepted: 04/29/2014] [Indexed: 11/17/2022] Open
Abstract
Background In the aftermath of the global financial crisis, millions of households have been left with debts that they are unable to manage. Indebtedness may impair the wellbeing of those affected by it for years to come. This systematic review focuses on the long-term consequences of indebtedness on health. Methods The method used in the paper is a systematic review. First, bibliographic databases were searched for peer-reviewed articles. Second, the references and citations of the included articles were searched for additional articles. Results The results from our sample of 33 peer-reviewed studies demonstrate serious health effects related to indebtedness. Individuals with unmet loan payments had suicidal ideation and suffered from depression more often than those without such financial problems. Unpaid financial obligations were also related to poorer subjective health and health-related behaviour. Debt counselling and other programmes to mitigate debt-related stress are needed to alleviate the adverse effects of indebtedness on health. Conclusions The results demonstrate that indebtedness has serious effects on health.
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Affiliation(s)
- Elina Turunen
- Research Department, The Social Insurance Institution of Finland, PL 450, 00101 Helsinki, Finland.
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West-Oram P. Freedom of conscience and health care in the United States of america: the conflict between public health and religious liberty in the patient protection and affordable care act. HEALTH CARE ANALYSIS 2014; 21:237-47. [PMID: 23539432 DOI: 10.1007/s10728-013-0251-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The recent confirmation of the constitutionality of the Obama administration's Patient Protection and Affordable Care Act (PPACA) by the US Supreme Court has brought to the fore long-standing debates over individual liberty and religious freedom. Advocates of personal liberty are often critical, particularly in the USA, of public health measures which they deem to be overly restrictive of personal choice. In addition to the alleged restrictions of individual freedom of choice when it comes to the question of whether or not to purchase health insurance, opponents to the PPACA also argue that certain requirements of the Act violate the right to freedom of conscience by mandating support for services deemed immoral by religious groups. These issues continue the long running debate surrounding the demands of religious groups for special consideration in the realm of health care provision. In this paper I examine the requirements of the PPACA, and the impacts that religious, and other ideological, exemptions can have on public health, and argue that the exemptions provided for by the PPACA do not in fact impose unreasonable restrictions on religious freedom, but rather concede too much and in so doing endanger public health and some important individual liberties.
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Thomas LV, Wedel KR. Nonemergency medical transportation and health care visits among chronically ill urban and rural medicaid beneficiaries. SOCIAL WORK IN PUBLIC HEALTH 2014; 29:629-639. [PMID: 25144703 DOI: 10.1080/19371918.2013.865292] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2013] [Accepted: 11/10/2013] [Indexed: 06/03/2023]
Abstract
Inaccessibility to health care services due to lack of transportation affects the most vulnerable segments of the society. The effect of Medicaid-provided nonemergency medical transportation (NEMT) in Oklahoma on health care visits for the management of chronic illnesses is examined. Analyses of claims data show that African Americans are the highest users of NEMT. Medicaid beneficiaries who use NEMT services are significantly more likely to make the recommended number of annual visits for the management of chronic conditions than those who do not use NEMT. Increased use of NEMT by making the services more accommodating and convenient for beneficiaries is proposed.
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Affiliation(s)
- Leela V Thomas
- a Department of Social Work, College of Education, Health & Public Policy , Delaware State University , Dover , Delaware , USA
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Abstract
Most American households carry debt, yet we have little understanding of how debt influences health behavior, especially health care seeking. We examined associations between foregone medical care and debt using a population-based sample of 914 southeastern Michigan residents surveyed in the wake of the late-2000s recession. Overall debt and ratios of debt to income and debt to assets were positively associated with foregoing medical or dental care in the past 12 months, even after adjusting for the poorer socioeconomic and health characteristics of those foregoing care and for respondents' household incomes and net worth. These overall associations were driven largely by credit card and medical debt, while housing debt and automobile and student loans were not associated with foregoing care. These results suggest that debt is an understudied aspect of health stratification.
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Affiliation(s)
- Lucie Kalousova
- Department of Sociology, University of Michigan, Ann Arbor, MI 48103, USA.
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Christy K, Hampton-Stover E, Shobe M, Hammig B. Perceived health status and health insurance status: protective factors against health-related debt? SOCIAL WORK IN HEALTH CARE 2013; 52:525-537. [PMID: 23865970 DOI: 10.1080/00981389.2012.742481] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Current health care debate has largely focused on the need for health insurance coverage rather than quality coverage. Yet the economic downturn has resulted in an increasing number of individuals who are uninsured or underinsured, and consequently face financial hardships. Multivariate analyses were used with 95 adults to examine relationships between health insurance, health status, and health debt. Controlling for demographics, and human and financial capital, findings suggest that health debt is not related to health insurance or health status. However, individuals with post-secondary education and non-homeowners appear to be more at risk for accumulating health debt.
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Affiliation(s)
- Kameri Christy
- School of Social Work , University of Arkansas, Fayetteville, Arkansas 72701, USA.
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Shah SJ, Krumholz HM, Reid KJ, Rathore SS, Mandawat A, Spertus JA, Ross JS. Financial stress and outcomes after acute myocardial infarction. PLoS One 2012; 7:e47420. [PMID: 23112814 PMCID: PMC3480393 DOI: 10.1371/journal.pone.0047420] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 09/14/2012] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Little is known about the association between financial stress and health care outcomes. Our objective was to examine the association between self-reported financial stress during initial hospitalization and long-term outcomes after acute myocardial infarction (AMI). MATERIALS AND METHODS We used prospective registry evaluating myocardial infarction: Event and Recovery (PREMIER) data, an observational, multicenter US study of AMI patients discharged between January 2003 and June 2004. Primary outcomes were disease-specific and generic health status outcomes at 1 year (symptoms, function, and quality of life (QoL)), assessed by the Seattle Angina Questionnaire [SAQ] and Short Form [SF]-12. Secondary outcomes included 1-year rehospitalization and 4-year mortality. Hierarchical regression models accounted for patient socio-demographic, clinical, and quality of care characteristics, and access and barriers to care. RESULTS Among 2344 AMI patients, 1241 (52.9%) reported no financial stress, 735 (31.4%) reported low financial stress, and 368 (15.7%) reported high financial stress. When comparing individuals reporting low financial stress to no financial stress, there were no significant differences in post-AMI outcomes. In contrast, individuals reporting high financial stress were more likely to have worse physical health (SF-12 PCS mean difference -3.24, 95% Confidence Interval [CI]: -4.82, -1.66), mental health (SF-12 MCS mean difference: -2.44, 95% CI: -3.83, -1.05), disease-specific QoL (SAQ QoL mean difference: -6.99, 95% CI: -9.59, -4.40), and be experiencing angina (SAQ Angina Relative Risk = 1.66, 95%CI: 1.19, 2.32) at 1 year post-AMI. While 1-year readmission rates were increased (Hazard Ratio = 1.50; 95%CI: 1.20, 1.86), 4-year mortality was no different. CONCLUSIONS High financial stress is common and an important risk factor for worse long-term outcomes post-AMI, independent of access and barriers to care.
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Affiliation(s)
- Sachin J. Shah
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Harlan M. Krumholz
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Section of Health Policy and Administration, Department of Epidemiology and Public Health and Section of Cardiovascular Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Kimberly J. Reid
- Department of Cardiology, Mid America Heart Institute of St. Luke’s Hospital, Kansas City, Missouri, United States of America
| | - Saif S. Rathore
- Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - Aditya Mandawat
- Department of Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts, United States of America
| | - John A. Spertus
- Department of Cardiology, Mid America Heart Institute of St. Luke’s Hospital, Kansas City, Missouri, United States of America
- Department of Cardiology, University of Missouri-Kansas City, Kansas City, Missouri, United States of America
| | - Joseph S. Ross
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Section of General Internal Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
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