The Joint Distribution Of High Out-Of-Pocket Burdens, Medical Debt, And Financial Barriers To Needed Care

Health care financial pressures in the US can manifest themselves in a variety of ways. Some families face high out-of-pocket spending on insurance premiums and medical care relative to income and assets. Some face medical debt that must be paid off over time. And some face delays or go without needed care for reasons involving cost. Whereas prior research has generally focused on these problems separately, a more complete picture of the challenges facing US families can be obtained by examining the joint distribution of these three financial problems. Applying relatively strict definitions of financial problems to data from the 2018-19 Medical Expenditure Panel Survey, we found that 27.0 percent of nonsenior adults lived in families with at least one of the three financial strains assessed. The share of participants facing more broadly defined financial problems was 45.4 percent. Prevalence varied across sociodemographic characteristics, families' health care needs, insurance coverage, and financial resources. The wide distribution of financial strain provides context for ongoing reforms in billing, coverage, and medical debt, as well as for the urgency felt across the country for health care financing reform.

Patient factors that affect opioid use among adults with and without chronic pain

BACKGROUND

In recent years, inappropriate use of prescription opioids has become a national crisis. Prescription opioids can be an important tool for managing pain, but excessive dosages or extended use may lead to drug dependence, overdoses and mortality. Since the early 2000s, increased prescribing of opioids has been associated with marked increases in these adverse outcomes.

OBJECTIVE

To determine patient characteristics associated with opioid use among adults with and without chronic pain treatment.

METHODS

The study is based on a nationally representative sample of civilian noninstitutionalized adults without cancer from the Medical Expenditure Panel Survey (2014-2017). A multinomial logit regression analysis is used. Key patient characteristics are health attitudes. Self-reliant health attitude is agreement with the following statements: "I do not need health insurance," and "I can overcome illness without help from a medically trained person."

RESULTS

Health-related attitudes affect both adults with and without chronic pain treatment similarly. Adults with self-reliant health attitudes are less likely to start and more likely to discontinue opioid use. Exercise is associated with higher probability of choosing no analgesic treatments over using opioids. Similarly, among adults who are using opioids for pain treatment, exercise is associated with higher probability of discontinuing opioid use in the year following opioid initiation.

CONCLUSIONS AND RELEVANCE

Health related attitudes, self-reported mental health, and lifestyle choices such as exercise and smoking are associated with patients' choices among opioid and non-opioid treatments. These results can help clinicians guide patients towards non-opioid treatments.

Hospital Finances and Patient Safety Outcomes

Hospitals recently have experienced greater financial pressures. Whether these financial pressures have led to more patient safety problems is unknown. Using the Healthcare Cost and Utilization Project (HCUP) State Inpatient Data for Florida from 1996 to 2000, this study examines whether financial pressure at hospitals is associated with increases in the rate of patient safety events (e.g., medical errors) for major surgeries. Findings show that patients have significantly higher odds of having adverse patient safety events (nursing-related patient safety events, surgery-related patient safety events, and all likely preventable patient safety events) when hospital profit margins decline over time. The finding that a within-hospital erosion of hospital operating profits increases the rate of adverse patient safety events suggests that any cost-cutting efforts be carefully designed and managed.

Changes in pharmaceutical treatment of diabetes and family financial burdens

Recent changes in diabetes treatment guidelines and the introduction of new, more expensive pharmaceuticals appear to increase the financial challenges for nonelderly adults with diabetes. The authors used Medical Expenditure Panel Survey data to examine changes in the prevalence of diabetes and comorbidities, diabetes treatment, financial burdens, and the relationship between high financial burdens and patient characteristics. From 1997-1998 to 2006-2007, the total number of nonelderly adults treated for diabetes nearly doubled, from 5.4 to 10.7 million, and the proportion of diabetes patients using multiple drugs to treat their condition increased significantly. About a fifth of diabetes patients spent 10% or more of their family income on health care, and about one in nine spent 20% or more of their family income on health care. In 2006-2007, diabetes patients who were older, female, in poor health, or lacked insurance were more likely than others to have high burdens.

Wealth, income, and the affordability of health insurance

There have been debates over how many uninsured people can afford insurance but refuse to purchase it. Examining the difference in asset holdings between the privately insured and the uninsured, we found that the difference in purchasing power is not fully revealed by income comparisons. Median income among the privately insured is 2.9 times that of the uninsured, but median wealth among those with private insurance is 23.2 times that of the uninsured. Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.

Advances in bariatric surgery for obesity: laparoscopic surgery

CONTEXT

The most advanced and fastest growing form of bariatric surgery is laparoscopic gastric bypass. Very little is known about population-based 180-day laparoscopic bypass costs, complication rates, readmission rates, and post-operative care.

OBJECTIVE

To examine the 6-month costs and outcomes of laparoscopic vs. open bariatric bypass surgery using a national population-based sample.

DESIGN

We use the 1998-2003 Nationwide Inpatient Sample to examine national trends in the rate of laparoscopic bypass. To examine postoperative outcomes, we examine insurance claims for 2,384 bariatric bypass surgeries, at 308 hospitals, among a population of 5.6 million non-elderly people covered by large employers across 49 states in 2001 and 2002. Multivariate logit regression analysis is performed to risk-adjust outcomes.

MAIN OUTCOME MEASURES

180-day outcomes: 12 complications specific to bariatric surgery and 44 general post-operative conditions, readmission rates, ER rates, and expenditures following bariatric surgery.

RESULTS

Between 1998 and 2003, the national percentage of bariatric bypass surgeries that were laparoscopic grew from 1.5 to 17.1%. There was no significant difference in in-hospital mortality between laparoscopy and open surgery. With the 2001-2002 claims data, we find that of the patients having bypass surgery, men had 48% lower odds of having laparoscopy and that high bariatric volume hospitals were close to four times more likely to use laparoscopy. Laparoscopic bypass, compared with open bypass, had 34% lower odds of a complication during the initial surgical stay, 27% lower odds of a 30-day complication, but no statistically significant difference in 180-day complications. Laparoscopy had 49% higher odds of having the general 44 post-operative conditions, with 45% higher odds of a readmission and 54% higher odds of an ER visit. However, overall, laparoscopy resulted in a 23% lower number of hospital days and 9% lower 180-day expenditures.

CONCLUSION

The laparoscopic cost-savings during the less invasive initial surgery stay outweigh the increase in post-discharge utilization. Further cost-savings will only emerge from laparoscopy only if its late post-operative complications are reduced. More cost-savings will also emerge as more physicians switch to the use of laparoscopy for bypass surgery.

Financial burden of health care, 2001-2004

Analysis of data from the Medical Expenditure Panel Survey (MEPS) shows that rising out-of-pocket expenses and stagnant incomes increased health spending's financial burden for families in 2001-2004, especially for the privately insured. High financial burdens among those with nongroup coverage increased by more than one-third. Despite evidence of increased cost sharing in private insurance plans, our analysis does not show that privately insured people paid a higher share of their total health care bill in 2004 compared to 2001. Financial burdens have increased to the point at which private insurance is no longer able to provide financial protection for an increasing number of families.

Changes in financial burdens for health care: national estimates for the population younger than 65 years, 1996 to 2003

CONTEXT

Policymakers as well as physicians need to understand how rapidly rising health care costs are affecting specific groups of patients.

OBJECTIVE

To estimate the number and characteristics of individuals in the United States faced with very high financial burdens for health care.

DESIGN, SETTING, AND POPULATION

Data from a nationally representative sample of civilian, noninstitutionalized US individuals younger than 65 years from the Medical Expenditure Panel Surveys were used to calculate 2 measures of financial burden as a function of tax-adjusted family income. Total burden included all out-of-pocket expenditures for health care services, including premiums. Health care services burden excluded premiums and, when applied to the insured population, was used to identify the underinsured. We defined the underinsured as insured persons with health care service burdens in excess of 10% of tax-adjusted family income.

MAIN OUTCOME MEASURES

Total and health care services burdens exceeding 10% and 20% of family income in 1996 and 2003.

RESULTS

In 2003, there were 48.8 million individuals (19.2%) living in families spending more than 10% of family income on health care, an increase of 11.7 million persons since 1996. Of these individuals, about 18.7 million (7.3%) were spending more than 20% of family income. In 2003, individuals with higher-than-average risk of incurring high total burdens included poor and low-income persons and those with nongroup coverage, aged 55 to 64 years, living in a non-metropolitan statistical area, in fair or poor health, having any type of limitation, or having a chronic medical condition. Applying our definition of underinsured to the insured population, an estimated 17.1 million persons younger than 65 years were underinsured in 2003, including 9.3 million persons with private employment-related insurance, 1.3 million persons with private nongroup policies, and 6.6 million persons with public coverage.

CONCLUSIONS

Our analysis identifies patients at greatest risk of health-related financial burdens that may adversely affect their access and adherence to recommended treatments. Our study also highlights the high costs associated with nongroup health insurance policies.

Healthcare Utilization and Outcomes After Bariatric Surgery

OBJECTIVE

Bariatric surgery is one of the fastest growing hospital procedures. Our objective is to examine the safety outcomes and utilization of resources in the 6 months after bariatric surgery using a nationwide, population-based sample. DATA/DESIGN: We examine insurance claims for 2522 bariatric surgeries, at 308 hospitals, among a population of 5.6 million nonelderly people covered by large employers in the 2001-2002 MarketScan data. Outcomes and costs were risk-adjusted using multivariate regression methods.

PRINCIPAL FINDINGS

Although the complication rate was 21.9% during the initial surgical stay, the rate increased by 81% (P < 0.01) to 39.6% (95% confidence interval, 37.7-41.5%) over the 180 days after discharge. A total of 10.8% of the patients without 30-day complications developed a complication between 30 days and 180 days. Overall, 18.2% of the patients had some type of postoperative visit to the hospital with a complication (through readmission, outpatient hospital visit, or emergency room visit) within 180 days. Although there was no difference between men and women, the near-elderly had a 26% (P < 0.01) higher risk-adjusted complication rate than those age 18 to 39 years. Total 6-month risk-adjusted healthcare payments were $65,031 for those with 180-day readmissions compared with $27,125 for those without readmissions (P < 0.01).

CONCLUSION

In contrast to current bariatric studies, which report a 20% in-hospital complication rate, we find a significantly higher complication rate over the 6 months after surgery, resulting in costly readmissions and emergency room visits. Thus, a clear way to reduce the costs and improve outcomes of bariatric surgery is to address the high rate of postoperative complications.

Workers Who Decline Employment-Related Health Insurance

BACKGROUND

Families of workers who decline coverage represent a substantial share of the uninsured and publicly-insured population in the United States.

OBJECTIVE

We examined health status, access to health care, utilization, and expenditures among families that declined health insurance coverage offered by employers using data from the Medical Expenditure Panel Survey for 2001 and 2002.

RESULTS

We found differences in insurance status for adults and children among families with offers. We found that among low-income families with offers, children are less likely to have private insurance compared with adults. However, the majority of children who decline private insurance end up with public coverage, whereas most of adults who decline offers remain uninsured. Decliners are more likely to report poor health, yet they are also less likely to have high cost medical conditions. Families declining coverage have weaker preferences for insurance than families that take up. Although access to care is lower among the decliners who remain uninsured, decliners with public insurance have similar access to care as those with private insurance. Families turning down coverage are more likely to face high expenditure burdens as a percentage of income and more likely to have financial barriers to care. Families who decline coverage rely heavily on the safety net. Public sources and uncompensated care account for 72% of total expenditures among adults who decline coverage.

CONCLUSIONS

Our results suggest that policy initiatives aimed at increasing take up among workers need to take into account the incentives workers face given the availability of care through public sources and uncompensated care.

Health care expenditure burdens among adults with diabetes in 2001

OBJECTIVE

High out-of-pocket costs can pose a significant burden on patients with chronic conditions such as diabetes and contribute to decreased treatment adherence. We examined financial burdens among adults with diabetes using nationally representative data.

METHODS

estimated how frequently adults with diabetes live in families in which spending on health insurance premiums and health care services exceed a specified percentage of family-level after-tax disposable income.

RESULTS

We found that adults with diabetes face greater risks of high burdens compared with adults with any other highly prevalent medical condition. Adults with diabetes have lower incomes and pay a higher share of total expenditures out-of-pocket compared with adults with heart disease, hypertension, and cancer. Among adults with diabetes, women, those who live in poverty, and those with coexisting conditions are more likely to bear high burdens. Among nonelderly adults, those with public coverage and the uninsured have greater risk of high burdens compared with those with private insurance. More than 23% of the uninsured and more than 20% of those with public coverage spend more than half of their disposable income on health care. Among the elderly, those with private nonemployment related insurance have the greatest risk of high burdens followed by those with Medicare only, those with private employment-related coverage, and those enrolled in Medicaid. Prescription medications and diabetic supplies account for 63% to 70% of out-of-pocket expenditures among the nonelderly and 62% to 69% among the elderly.

CONCLUSIONS

Our study identifies the subpopulations among adults with diabetes who are more likely to have high burdens, so that intervention measures can be targeted to help reduce treatment noncompliance. Our analysis also emphasizes the role of medications and diabetic supplies in contributing to high out-of-pocket burdens.

Use And Costs Of Bariatric Surgery And Prescription Weight-Loss Medications

The extent of use of bariatric surgery and weight-loss medications is unknown. Using the Nationwide Inpatient Sample, we estimate that the number of bariatric surgeries grew 400 percent between 1998 and 2002; such surgeries were performed on 0.6 percent of the 11.5 million adults clinically eligible in 2002. Hospital costs for bariatric surgery grew sixfold to $948 million in 2002. The inpatient death rate declined 64 percent. Among employers that covered weight-loss drugs in 2002, less than 2.4 percent of adults clinically eligible for these drugs used them, with average annual spending of $304 per user.

Tax Incidence and Net Benefits in the Market for Employment-Related Health Insurance: Sensitivity of Estimates to the Incidence of Employer Costs

The market for employment-related coverage contains public transfers through the tax system and private transfers across workers with predictably different risks. We examine both transfers across a wide range of employee characteristics, including age, race, ethnicity, family size, poverty level, and health risk. To resolve longstanding questions regarding the incidence of employer contributions, we simulate a range of alternative incidence scenarios in which (i) all employees offered coverage in a firm share equally in the employer's costs, (ii) burdens are narrowly targeted according to employee-specific health risks, and (iii) intermediate cases with burdens targeted by job characteristics, age, sex, race, ethnicity, and family size. Our results provide evidence regarding the distribution of tax subsidies and net benefits under a range of scenarios that we believe bound the true incidence of employer premium contributions.