Out-of-pocket medical expenses compared across five years for patients with one of five common cancers in Australia.

BACKGROUND: Patient medical out-of-pocket expenses are thought to be rising worldwide yet data describing trends over time is scant. We evaluated trends of out-of-pocket expenses for patients in Australia with one of five major cancers in the first-year after diagnosis. METHODS: Participants from the QSKIN Sun and Health prospective cohort Study with a histologically confirmed breast, colorectal, lung, melanoma, or prostate cancer diagnosed between 2011 and 2015 were included (n = 1965). Medicare claims data on out-of-pocket expenses were analysed using a two-part model adjusted for year of diagnosis, health insurance status, age and education level. Fisher price and quantity indexes were also calculated to assess prices and volumes separately. RESULTS: On average, patients with cancer diagnosed in 2015 spent 70% more out-of-pocket on direct medical expenses than those diagnosed in 2011. Out-of-pocket expenses increased significantly for patients with breast cancer (mean AU$2513 in 2011 to AU$6802 in 2015). Out-of-pocket expenses were higher overall for individuals with private health insurance. For prostate cancer, expenses increased for those without private health insurance over time (mean AU$1586 in 2011 to AU$4748 in 2014) and remained stable for those with private health insurance (AU$4397 in 2011 to AU$5623 in 2015). There were progressive increases in prices and quantities of medical services for patients with melanoma, breast and lung cancer. For all cancers, prices increased for medicines and doctor attendances but fluctuated for other medical services. CONCLUSION: Out-of-pocket expenses for patients with cancer have increased substantially over time. Such increases were more pronounced for women with breast cancer and those without private health insurance. Increased out-of-pocket expenses arose from both higher prices and higher volumes of health services but differ by cancer type. Further efforts to monitor patient out-of-pocket costs and prevent health inequities are required.

Impacts on employment, finances, and lifestyle for working age people facing an expected premature death: A systematic review.

ABSTRACTObjective:The working ages (25-65 years) are a period when most people have significant work, financial, and family responsibilities. A small proportion of working age people will face an expected premature death from cancer or other life-limiting illness. Understanding the impact an expected premature death has on this population is important for informing support. The current study set out to summarize research describing the effects that facing an expected premature death has on employment, financial, and lifestyle of working age people and their families. METHOD: A systematic review using narrative synthesis approach. Four electronic databases were searched in July 2016 for peer-reviewed, English language studies focusing on the financial, employment, and lifestyle concerns of working age adults living with an advanced life-limiting illness and/or their carers and/or children. RESULTS: Fifteen quantitative and 12 qualitative studies were included. Two-thirds (n = 18) were focused on cancer. All studies identified adverse effects on workforce participation, finances, and lifestyle. Many patients were forced to work less or give up work/retire early because of symptoms and reduced functioning. In addition to treatment costs, patients and families were also faced with child care, travel, and home/car modification costs. Being younger was associated with greater employment and financial burden, whereas having children was associated with lower functional well-being. Changes in family roles were identified as challenging regardless of diagnosis, whereas maintaining normalcy and creating stability was seen as a priority by parents with advanced cancer. This review is limited by the smaller number of studies focussing on the needs of working age people with nonmalignant disease. SIGNIFICANCE OF RESULTS: Working age people facing an expected premature death and their families have significant unmet financial, employment, and lifestyle needs. Comparing and contrasting their severity, timing, and priority for people with nonmalignant conditions is required to better understand their unique needs.

Financial impact of the GFC: health care spending across the OECD.

Since the onset of the global financial crisis (GFC), health spending has slowed markedly or fallen in many OECD countries after years of continuous growth. However, health spending patterns across the 34 countries of the OECD have been affected to varying degrees. This article examines in more detail the observed downturn in health expenditure growth, analysing which countries and which sectors of health spending have been most affected. In addition, using more recent preliminary data for a subset of countries, this article tries to shed light on the prospects for health spending trends. Given that public sources account for around three-quarters of total spending on health on average across the OECD, and, in an overall context of managing public deficits, the article focuses on the specific areas of public spending that have been most affected. This study also tries to link the observed trends with some of the main policy measures and instruments put in place by countries. The investigation finds that while nearly all OECD countries have seen health spending growth decrease since 2009, there is wide variation as to the extent of the slowdown, with some countries outside of Europe continuing to see significant growth in health spending. While all sectors of spending appear to have been affected, initial analysis appears to show the greatest decreases has been experienced in pharmaceutical spending and in areas of public health and prevention.

Private health care expenditure and quality in Beveridge systems: cross-regional differences in the Italian NHS.

Private health care expenditure ranges from 15% to 30% of total healthcare spending in OECD countries. The literature suggests that there should be an inverse correlation between quality of public services and private expenditures. The main objective of this study is to explore the association between quality of public healthcare and private expenditures in the Italian Regional Healthcare Systems (RHSs). The institutional framework offered by the Italian NHS allows to investigate on the differences among the regions while controlling for institutional factors. The study uses micro-data from the ISTAT Household Consumption Survey (HCS) and a rich set of regional quality indicators. The results indicate that there is a positive and significant correlation between quality and private spending per capita across regions. The study also points out the strong association between the distribution of private consumption and income. In order to account for the influence of income, the study segmented data in three socio-economic classes and computed cross-regional correlations of RHSs quality and household healthcare expenditure per capita, within each class. No correlation was found between the two variables. These findings are quite surprising and call into question the theory that better quality of public services crowds out private spending, or, at the very least, it undermines the simplistic notions that higher levels of private spending are a direct consequence of poor quality in the public sector. This suggests that policies should avoid to simplistically link private spending with judgements or assessments about the functioning or efficacy of the public system and its organizations.

Time trend of out-of-pocket expenditure among cancer inpatients: evidence from Korean tertiary hospitals.

BACKGROUND: This study aimed to examine out-of-pocket expenditure for cancer treatments of hospitalized patients and to analyze changing patterns over time. MATERIALS AND METHODS: This study examined data of all cancer patients receiving inpatient care from two tertiary hospitals from January 2003 to December 2010. Medical expenditures per admission were calculated and classified into those covered and uncovered by the Korean National Health Insurance (NHI) and co-payment. RESULTS: The medical expenditure per admission increased slowly from 3,455 thousand Korean won (KRW) to 4,068 thousand KRW. While expenditures covered by the NHI have increased annually, co-payments have generally decreased. The out-of-pocket expenditure ratio, which means the proportion of uncovered expenditure and co-payment among total medical expenditure dropped sharply from 2005 to 2007 and was maintained at a similar level after 2007. Medical expenditures, NHI coverage, and the out-of-pocket expenditure ratio differed across cancer types. CONCLUSIONS: It is necessary to continually monitor the expenditure of uncovered services by the NHI, and to provide policies to reduce this economic burden. In addition, an individual approach considering cancer type-specific characteristics and medical utilization should be provided.

Problems and the potential direction of reforms for the current individual medical savings accounts in the Chinese health care system.

Individual health savings accounts are an important part of the current basic medical insurance system for urban workers in China. Since 1998 when the system of personal medical insurance accounts was first implemented, there has been considerable controversy over its function and significance within different social communities. This paper analyzes the main problems in the practical implementation of individual medical insurance accounts and discusses the social and cultural foundations for the establishment of family health savings accounts from the perspective of Chinese Confucian familism. Accordingly, it addresses the direction of the reform and the development of the current system of individual health insurance accounts in China.

The redistributive effect of the move from age-based to income-based prescription drug coverage in British Columbia, Canada.

OBJECTIVES: To explore the redistributive impact of two different pharmaceutical financing policies (age-based versus income-based pharmacare) on the distribution of income in British Columbia (B.C.), Canada. METHODS: Using household-level data on all payments that are used to finance prescription drugs in B.C. (including taxation and private payments), we performed a redistributive analysis to indicate how much income inequality in the province changed as a result of payments made for prescription drugs. We also illustrated changes in vertical equity (different treatment according to ability-to-pay) and horizontal equity (equals, according to ability-to-pay, being treated equally) between the two years separately through a pre-post policy examination. RESULTS: We found that payments made to finance prescription drugs increased overall income inequality in the province. This negative impact was larger after the move to income-based pharmacare. Our results also show increasing horizontal inequity after the policy change, and suggest that the increased reliance on out-of-pocket payments was a major source of the negative impact on the B.C.'s overall income distribution. We also show that the consequences of the move to income-based pharmacare would have been less severe had the level of public financing not decreased substantially between the two years. CONCLUSIONS: The increase in income inequality in B.C. following the policy change was an unintended consequence of the move to income-based pharmacare. This finding is worth consideration as countries and jurisdictions weigh pharmaceutical policy alternatives.

Lung cancer treatment costs, including patient responsibility, by disease stage and treatment modality, 1992 to 2003.

OBJECTIVES: The objective of this analysis was to estimate costs for lung cancer care and evaluate trends in the share of treatment costs that are the responsibility of Medicare beneficiaries. METHODS: The Surveillance, Epidemiology, and End Results (SEER)-Medicare data from 1991-2003 for 60,231 patients with lung cancer were used to estimate monthly and patient-liability costs for clinical phases of lung cancer (prediagnosis, staging, initial, continuing, and terminal), stratified by treatment, stage, and non-small- versus small-cell lung cancer. Lung cancer-attributable costs were estimated by subtracting each patient's own prediagnosis costs. Costs were estimated as the sum of Medicare reimbursements (payments from Medicare to the service provider), co-insurance reimbursements, and patient-liability costs (deductibles and "co-payments" that are the patient's responsibility). Costs and patient-liability costs were fit with regression models to compare trends by calendar year, adjusting for age at diagnosis. RESULTS: The monthly treatment costs for a 72-year-old patient, diagnosed with lung cancer in 2000, in the first 6 months ranged from $2687 (no active treatment) to $9360 (chemo-radiotherapy); costs varied by stage at diagnosis and histologic type. Patient liability represented up to 21.6% of care costs and increased over the period 1992-2003 for most stage and treatment categories, even when care costs decreased or remained unchanged. The greatest monthly patient liability was incurred by chemo-radiotherapy patients, which ranged from $1617 to $2004 per month across cancer stages. CONCLUSIONS: Costs for lung cancer care are substantial, and Medicare is paying a smaller proportion of the total cost over time.

[Out-of-pocket health care expenditures among population groups in Iceland]. / Bein útgjöld íslenskra heimila vegna heilbrigdismála.

OBJECTIVE: Out-of-pocket health expenditures affect access to health care. The study investigated trends in these expenditures, and whether certain population groups spent more than others. MATERIAL AND METHODS: The data come from two national health surveys among Icelandic adults from 1998 and 2006. The response rate was 69% in the former survey (N=1924), and 60% in the latter (N= 1532). Average household health expenditures and household expenditure burden (expenditures as % of total household income) were compared over time and between groups. RESULTS: Household health expenditures increased by 29% in real terms between 1998 and 2006. The biggest items in 2006 were drugs and dental care. Women, younger and older individuals, the single and divorced, smaller households, the unemployed and non-employed, individuals with low education and income, the chronically ill, and the disabled, had the highest household expenditure burden. Comparison between 1998 and 2006 indicated increased expenditure burden among young people, students, the unemployed, and the least educated, but decreased burden among the elderly, the widowed, and parents of young children. CONCLUSIONS: Household health expenditures differ substantially between groups, suggesting reconsideration of current health insurance policies, especially with regard to disabled, non-employed, low-income, and young individuals.

Health reform in central and eastern Europe and the former Soviet Union.

In the two decades since the fall of the Berlin Wall, former communist countries in Europe have pursued wide-ranging changes to their health systems. We describe three key aspects of these changes-an almost universal switch to health insurance systems, a growing reliance on out-of-pocket payments (both formal and informal), and efforts to strengthen primary health care, often with a model of family medicine delivered by general practitioners. Many decisions about health policy, such as the introduction of health insurance systems or general practice, took into account political issues more than they did evidence. Evidence for whether health reforms have achieved their intended results is sparse. Of crucial importance is that lessons are learnt from experiences of countries to enable development of health systems that meet present and future health needs of populations.

Thirty years of national health insurance in South Korea: lessons for achieving universal health care coverage.

South Korea introduced mandatory social health insurance for industrial workers in large corporations in 1977, and extended it incrementally to the self-employed until it covered the entire population in 1989. Thirty years of national health insurance in Korea can provide valuable lessons on key issues in health care financing policy which now face many low- and middle-income countries aiming to achieve universal health care coverage, such as: tax versus social health insurance; population and benefit coverage; single scheme versus multiple schemes; purchasing and provider payment method; and the role of politics and political commitment. National health insurance in Korea has been successful in mobilizing resources for health care, rapidly extending population coverage, effectively pooling public and private resources to purchase health care for the entire population, and containing health care expenditure. However, there are also challenges posed by the dominance of private providers paid by fee-for-service, the rapid aging of the population, and the public-private mix related to private health insurance.

Hong Kong's domestic health spending--financial years 1989/90 through 2004/05.

This report presents the latest estimates of Hong Kong's domestic health spending between fiscal years 1989/90 and 2004/05, cross-stratified and categorised by financing source, provider and function on an annual basis. Total expenditure on health was HK$67,807 million in fiscal year 2004/05. In real terms, total expenditure on health showed positive growth averaging 7% per annum throughout the period covered in this report while gross domestic product grew at 4% per annum on average, indicating a growing percentage of health spending relative to gross domestic product, from 3.5% in 1989/90 to 5.2% in 2004/05. This increase was largely driven by the rise in public spending, which rose 9% per annum on average in real terms over the period, compared with 5% for private spending. This represents a growing share of public spending from 40% to 55% of total expenditure on health during the period. While public spending was the dominant source of health financing in 2004/05, private household out-of-pocket expenditure accounted for the second largest share of total health spending (32%). The remaining sources of health finance were employer-provided group medical benefits (8%), privately purchased insurance (5%), and other private sources (1%). Of the $67,807 million total health expenditure in 2004/05, current expenditure comprised $65,429 million (96%) while $2378 million (4%) were capital expenses (ie investment in medical facilities). Services of curative care accounted for the largest share of total health spending (67%) which were made up of ambulatory services (35%), in-patient curative care (28%), day patient hospital services (3%), and home care (1%). The next largest share of total health expenditure was spent on medical goods outside the patient care setting (10%). Analysed by health care provider, hospitals accounted for the largest share (46%) and providers of ambulatory health care the second largest share (30%) of total health spending in 2004/05. We observed a system-wide trend towards service consolidation at institutions (as opposed to free-standing ambulatory clinics, most of which are staffed by solo practitioner). In 2004/05, public expenditure on health amounted to $35,247 million (53.9% of total current expenditure), which was mostly incurred at hospitals (76.5%), whilst private expenditure ($30,182 million) was mostly incurred at providers of ambulatory health care (54.6%). This reflects the mixed health care economy of Hong Kong where public hospitals generally account for about 90% of total bed-days and private doctors (including Western and Chinese medicine practitioners) provide 75% to 80% of out-patient care. While both public and private spending were mostly expended on personal health care services and goods (92.9%), the distributional patterns among functional categories differed. Public expenditure was targeted at in-patient care (54.2%) and substantially less on out-patient care (24.5%), especially low-intensity first-contact care. In comparison, private spending was mostly concentrated on out-patient care (49.6%), whereas medical goods outside the patient care setting (22.6%) and in-patient care (18.8%) comprised the majority of the remaining share. Compared to OECD countries, Hong Kong has devoted a relatively low percentage of gross domestic product to health in the last decade. As a share of total spending, public funding (either general government revenue or social security funds) was also lower than in most comparably developed economies, although commensurate with its public revenue collection base.

Analysis of national annual variation in total patient out-of-pocket Medicare Part D stand-alone prescription drug plan costs from 2007 to 2008.

OBJECTIVE: This is the first study to compare total Medicare Part D (MPD) stand-alone prescription drug plan (PDP) estimated annual costs (EAC) between 2007 and 2008 in all MPD regions of the US using a patient cohort of Medicare-eligible patients. METHODS: A total of 50 patients were selected at random from a database of Medicare-eligible patients. Each patient profile, based on pharmacy claims data, was entered into the Medicare website and the EAC of each PDP in each of the 34 MPD regions was obtained. The lowest, 25th percentile, median and highest EAC plans were obtained for each patient in each region for 2007 and 2008. Pair-wise, within-region, between-year comparisons were made using the Wilcoxon Signed-Ranks test. RESULTS: Annual trends were variable between MPD regions. Only the highest EAC showed significant decreases in some regions, while all other comparisons showed no change or an increase in regional costs. CONCLUSIONS: Out-of-pocket Medicare prescription drug costs increased from 2007 to 2008. Increases in plan costs highlight the need for annual re-evaluation of PDP costs so that the patient is able to obtain the lowest cost plan each year. The decrease in the highest cost plan may suggest improvements in formulary coverage.

Smoking cessation and financial stress.

BACKGROUND: Research on the financial consequences of quitting smoking is scant. We examined the association of smoking cessation with the subsequent likelihood of experiencing financial stress. METHODS: Data came from Waves 1, 2 and 3 (2001-04) of the Household Income and Labour Dynamics in Australia survey. The size of the subsample of smokers in Wave 1 who also participated in Waves 2 and 3 was 1747. We compared respondents who reported to have been a smoker in all three waves with those who were smokers only in Wave 1. Eight questionnaire items were used to construct a binary financial stress indicator. RESULTS: The odds of experiencing financial stress in Wave 3 were 42% (95% CI: 6-74%; P=0.028) smaller for quitters than for continued smokers. CONCLUSIONS: Interventions to encourage smoking cessation among disadvantaged groups are likely to enhance their material conditions and standards of living, and to reduce socio-economic disparities in mortality.

[18 months law for the modernisation of the SHI--review and prospects]. / 18 Monate GKV-Modernisierungsgesetz--Bewertung und Ausblick: die Sicht der Krankenkassen.

Balance of the law for the modernisation of the statutory health insurance (SHI) (GKV-Modernisierungsgesetz-GMG) is contradictory as measured by the original objectives. Although the legislators curtailed benefits and raised the co-payments, those insured could not profit from lower contributions. The anticipated lowering of the ancillary wage costs was missing thereby. However, many SHI funds could settle debts, but the expenditures rose again in 2005. The financial situation of most SHI funds is still strained. The new federal government will have to tackle a further and sustainable reform of the statutory health insurance soon.

["Suddenly, no more money was left". The role of financing in the Austrian mental health care reform]. / "Dann war auf einmal kein Geld mehr da!". Zur Rolle der Finanzierung in der österreichischen Psychiatriereform.

OBJECTIVE: The article studies the role of financing mental health care for the mental health care service structure in the process of moving towards a patient-oriented and decentralised mental health care system. METHOD: The analysis is based on a description of the Austrian mental health care financing system and a discourse-analytical examination of reform documents and interviews with key actors in this country. RESULTS: Existing structures of mental health care services are a reflection of mental health care financing structures. Reform goals are in various forms linked to financing issues. However, an explicit discussion of the finance issues in reform documents is widely missing. CONCLUSIONS: Adapting the finance of mental health care to new paradigms of mental health care provision requires not just technical modifications, but also improved transparency of processes and implications involved.

The effects of drug subsidies on out-of-pocket prescription drug expenditures by seniors: regional evidence from Canada.

Between 1970 and 1986, all Canadian provinces introduced some version of a prescription drug subsidy for those aged 65 years or over and since 1986, all the provinces have increased copayments or deductibles to some degree. Employing a first-order approximation to the welfare gains from a subsidy, we find evidence that these subsidies have been less redistributive than an absolute per household cash transfer but slightly more redistributive than a transfer that would increase each household's income by the same percentage. Such evidence may have relevance for predicting the redistributive effects of a potential national prescription drug plan for seniors in the US.