Disparities of Access, Use, and Barriers to Seeking Health Care Services in Arizona.

BACKGROUND: Access to health care (HC) services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all persons. OBJECTIVES: We assess social indicators among people living in Arizona that are associated with access, use, and barriers to seeking HC services. RESEARCH DESIGN: We analyzed data (n=8073) from the 2018 Behavioral Risk Factor Surveillance System (BRFSS) to describe demographic and health characteristics among persons by HC access and use, and for whom costs were a barrier to seeking care. RESULTS: Among Arizona adults, 13.5% reported lacking HC coverage, 28.7% reported lacking a personal doctor, and medical costs were a barrier to seeking care for 14.1%. Arizonans aged 18-34 years or with a high school education or less more often reported lacking HC coverage, a personal doctor, or not visiting a doctor because of costs. Past year medical and dental checkups were less common among less educated (≤high school) and never married persons. Hispanic persons more often reported lacking HC coverage or not visiting a doctor because of costs, and less often reported past year dental checkups. CONCLUSIONS: BRFSS can be analyzed to identify and quantify unique HC disparities, and the findings can serve as the basis for improving HC in communities. Expansion of HC services and providers may be achieved, in part, through incentives for providers to work in designated health professional shortage areas and/or leveraging telehealth/telemedicine in rural and urban underserved communities.

Catastrophic expenditure and impoverishment after caesarean section in Sierra Leone: An evaluation of the free health care initiative.

BACKGROUND: Utilizing surgical services, including caesarean sections, can result in catastrophic expenditure and impoverishment. In 2010, Sierra Leone introduced the Free Health Care Initiative (FHCI), a national financial risk protection program for the most vulnerable groups. Aim of this study was to investigate catastrophic expenditure and impoverishment related to caesarean section in Sierra Leone and evaluate the impact of the FHCI. METHODS: Women who delivered by caesarean section in nine hospitals were followed up with home visits one month after surgery, and data on medical and non-medical expenditures were collected. Individual income was estimated based on household characteristics and used to determine catastrophic expenditure and impoverishment for each patient. The impact of the FHCI was assessed by comparing actual expenditure with counterfactual expenditures had the initiative not existed. RESULTS: For the 1146 patients in the study, the median expenditure was 23 (IQR 4; 56) international dollars (Int$). Patients in the poorest quintile spent a median Int$ 59 (IQR 28; 76), which was significantly more than patients in the richest quintile, who spent a median Int$ 17 (IQR 2; 38, p<0.001). Travel (32.9%) and food (28.7%) were the two largest expenses. Catastrophic expenditure was encountered by 12.0% and 4.0% (10% and 25% threshold, respectively) of the women. Without the FHCI, 66.1% and 28.8% of the women would have encountered catastrophic expenditure. CONCLUSION: Many women in Sierra Leone face catastrophic expenditure related to caesarean section, mainly through food and travel expenses, and the poor are disproportionally affected. The FHCI is effective in reducing the risk of catastrophic expenditure related to caesarean section, but many patients are still exposed to financial hardship, suggesting that additional support is needed for Sierra Leone's poorest patients.

How do patients prefer specialized clinical pharmacy service to other prevention of mother-to-child transmission of human immunodeficiency virus services? An evaluation of their willingness to pay and willingness to accept choices and ratios.

WHAT IS KNOWN AND OBJECTIVE: Donor agencies provide most of the funds for HIV services in developing countries. Due to the global economic downturn, there has been a reduction in funding for HIV-related services in Nigeria. This study compared the willingness to pay (WTP)-willingness to accept (WTA) ratios for prevention of mother-to-child transmission (PMTCT) services to specialized clinical pharmacy services among patients of two Nigerian hospitals. METHODS: This was a cross-sectional survey using contingent valuation method at Ahmadu Bello University Teaching Hospital (ABUTH) and University of Nigeria Teaching Hospital (UNTH). WTP and WTA were elicited using an interviewer-administered questionnaire and a payment card. The responses to the WTP and WTA questions were reported as frequencies and percentages, while the amounts were determined as mean. All costs were obtained in Nigerian Naira (N360 = $1). RESULTS AND DISCUSSION: Of the 219 mothers who participated in the study, 172 (78.5%) had no health insurance. Primary prevention of HIV (PPV) had the highest "yes" WTP response of 152 (69.4%) and the highest mean WTP amount of N6067.20. It also had the least "no" WTA response of 162 (74.0%) and the least WTA amount of N232.09. Specialized clinical pharmacy service (SCPS) had the highest WTA/WTP ratio of 4.0826 in ABUTH and 9.3750 at UNTH. Its income effect was -3.0826. A 1% increase in income led to 0.0550 (95% CI: -0.3068 to 0.1968) decreased odds to pay for PPV. WHAT IS NEW AND CONCLUSION: Most patients assessed in this study were willing to pay for PPV than other services. Majority of them were also willing to forgo PMTCT Drugs Only. SCPS had the highest value for the patients, but they did not want to pay a high amount for it. Employment status, health insurance status, educational level and age were predictors of patients' WTP and WTA.

Caregiver's difficulty paying child's healthcare bills and bullying victimization of adolescents with physical disabilities.

Guided by the ecological systems perspective, the objective of the study was to examine whether caregivers' difficulty paying their child's health-care bills is associated with bullying victimization directly and indirectly through the mediating mechanisms of caregivers' frustration, adolescents' internalizing problems, and social difficulty focusing on adolescents with physical disabilities. The 2019 National Survey of Children's Health dataset, which collected data on adolescents' and caregivers' demographic characteristics and health and well-being, was used. The study sample consisted of 368 caregivers of adolescents, 12-17 years of age with physical disabilities. No direct association between caregivers' difficulty paying their child's health-care bills and bullying victimization was found. However, caregivers' frustration and adolescents' internalizing problems were shown to have an indirect association with bullying victimization, which was mediated by difficulty making friends. In addition, adolescents' difficulty making friends was positively associated with bullying victimization. Practitioners working with adolescents with physical disabilities are encouraged to foster collaborative processes across various ecological systems of the adolescent and family to address caregivers' frustration and promote positive social and emotional development of the adolescent with physical disabilities, which can decrease their risk of bullying victimization.

Health Care Use and Out-of-pocket Spending by Persons With Dementia Differ Between Europe and the United States.

BACKGROUND: Persons with dementia need much care, but what care is used and how the burden of financing is divided between persons with dementia, caregivers, and public programs may differ between countries. OBJECTIVE: The objective of this study was to compare how health care use and out-of-pocket (OOP) spending associated with dementia differ between the United States and Europe, with and without controlling for background characteristics. RESEARCH DESIGN: We use prospectively collected survey data from the United States-based Health and Retirement Study (n=48,877) and the Survey of Health, Ageing, and Retirement in Europe (n=98,971) including all adults over the age of 70 years. Dementia status is imputed using a validated algorithm. After first reporting the observed differences in care use, we analyze how care use is associated with dementia using multivariate regressions, controlling for other health conditions and background characteristics. RESULTS: Persons with dementia in the United States use 50% less formal home care per year than persons living with dementia in Europe [mean (SD)=236.8 h (1047.4) vs. 463.3 h (1371.2)], but use more nursing home care [75.1 d (131.4) vs. 45.5 d (119.4)). Dementia is associated with higher OOP spending in the United States than Europe [4406 USD (95% confidence interval, 3914-4899) vs. 246 USD (73-418)-2017 price levels]. CONCLUSIONS: Health care use and OOP spending differ between Europe and the United States. The far greater reliance on nursing home care in the United States likely causes much higher expenditures for people with dementia and insurance programs alike.

Childhood Nutrition in Rural China: What Impact Does Public Health Insurance Have?

OBJECTIVES: To investigate the impact of public health insurance coverage, specifically the New Cooperative Medical Scheme (NCMS), on childhood nutrition in poor rural households in China, and to identify the mechanisms through which health insurance coverage affects nutritional intake. METHODS: Longitudinal data on 3291 children were taken from four time periods (2004, 2006, 2009, and 2011) from the China Health and Nutrition Survey (CHNS). Panel data analysis was performed with the fixed-effect model and the propensity score matching with difference-in-differences (PSM-DID) approach. RESULTS: The introduction of the NCMS was associated with a decline in calories, fat, and protein intake, and an increase in the intake of carbohydrates. The NCMS had the greatest negative effect on children aged 0 to 5 years, particularly girls. Out-of-pocket medical expenses were identified as the main channel through which the NCMS affected the nutritional intake of children. CONCLUSIONS: The study showed that the NCMS neither significantly improved the nutritional status of children nor enhanced intake of high-quality nutrients among rural poor households. These findings were attributed to the way in which health-seeking behavior was modified in the light of NCMS coverage. Specifically, NCMS coverage tended to increase healthcare utilization, which in turn increased out-of-pocket medical expenditures. This encouraged savings to aid financial risk protection and resulted in less disposable income for food consumption.

Factors associated with child delivery expenditure during the transition to the national implementation of the two-child policy in China.

BACKGROUND: This study aimed to analyze the status of birthrates and the characteristics of child delivery expenditure under the Chinese two-child policy's transition period. We evaluated the socioeconomic factors associated with child delivery and provide evidence for decisions relating to health support for childbirth. METHODS: Child delivery expense data were obtained from 2015 to 2017 in Dalian, China. A total of 13,535 obstetric records were enrolled using stratified random sampling and the proportional probability to size method. First, we calculated the current curative expenditure of child delivery and health financing in childbirth costs based on the System of Health Accounts 2011 (SHA 2011). Second, univariate analysis of variance and generalized linear modeling were performed to examine factors associated with child delivery expenditure. Third, we classified the included hospitals into the county, district, and municipal hospitals and compared maternal characteristics between these categories. RESULTS: Overall, out-of-pocket payments accounted for more than 35% of the total expenditure on child delivery. Median (interquartile range) delivery expenditure at the county and district level hospitals [county-level: 5128.50 (3311.75-5769.00) CNY; district-level: 4064.00 (2824.00-6599.00) CNY] was higher than that at the municipal level hospitals: 3824.50 (2096.50-5908.00) CNY. The increase of child delivery expenditure was associated with an increased ratio of reimbursement, admissions to county and district level hospitals, cesarean sections, and length of stay, as well as a decline in average maternal age (p < 0.05). CONCLUSIONS: Health financing for childbirth expenditure was not rational during the transition period of the family planning policy in China. Higher delivery expenditure at county and district level hospitals may indicate variations in medical professionalism. Poorly managed hospitalization expenditure and/or nonstandard medical charges for childbirth, all of which may require the development of appropriate public health policies to regulate such emerging phenomena.

Willingness to pay for private health insurance among workers with mandatory social health insurance in Mongolia.

BACKGROUND: High out-of-pocket health expenditure is a common problem in developing countries. The employed population, rather than the general population, can be considered the main contributor to healthcare financing in many developing countries. We investigated the feasibility of a parallel private health insurance package for the working population in Ulaanbaatar as a means toward universal health coverage in Mongolia. METHODS: This cross-sectional study used a purposive sampling method to collect primary data from workers in public and primary sectors in Ulaanbaatar. Willingness to pay (WTP) was evaluated using a contingent valuation method and a double-bounded dichotomous choice elicitation questionnaire. A final sample of 1657 workers was analyzed. Perceptions of current social health insurance were evaluated. To analyze WTP, we performed a 2-part model and computed the full marginal effects using both intensive and extensive margins. Disparities in WTP stratified by industry and gender were analyzed. RESULTS: Only < 40% of the participants were satisfied with the current mandatory social health insurance in Mongolia. Low quality of service was a major source of dissatisfaction. The predicted WTP for the parallel private health insurance for men and women was Mongolian Tugrik (₮)16,369 (p < 0.001) and ₮16,661 (p < 0.001), respectively, accounting for approximately 2.4% of the median or 1.7% of the average salary in the country. The highest predicted WTP was found for workers from the education industry (₮22,675, SE = 3346). Income and past or current medical expenditures were significantly associated with WTP. CONCLUSION: To reduce out-of-pocket health expenditure among the working population in Ulaanbaatar, Mongolia, supplementary parallel health insurance is feasible given the predicted WTP. However, given high variations among different industries and sectors, different incentives may be required for participation.

Exploring differences between private and public prices in the English care homes market.

This work quantitatively assesses the potential reasons behind the difference in prices paid by care home residents in England. Evidence suggests that the price paid by private payers is higher than that paid for publicly supported residents, and this is often attributed to the market power wielded by local authorities as the dominant purchaser in local markets. Estimations of private prices at the local authority level are used to assess the difference in price paid between private and public prices, the fees gap, using data from 2008 to 2010. Controlling for local area and average care home characteristics, the results indicate that both care home and local authority market power play a role in the price determination of the market.

The health care utilization and out-of-pocket expenditure associated with asthma amongst a sample of Australian women aged over 45 years: analysis from the '45 and up' study.

OBJECTIVE: This study aims to describe the prevalence of health care utilization (including conventional medicine, self-care and complementary medicine treatments) for the management of asthma by women aged 45 years and over and their associated out-of-pocket expenditure. METHODS: A self-reported mail survey of 375 Australian women, a cohort of the national 45 and Up Study, reporting a clinical diagnosis of asthma. The women were asked about their use of health care resources including conventional medicine, complementary medicine, and self-prescribed treatments for asthma and their associated out-of-pocket spending. Spearman's correlation coefficient, student's t-test and chi-square test were used as appropriate. Population level costs were created by extrapolating the costs reported by participants by available national prevalence data. RESULTS: Survey respondents (N = 375; response rate, 46.9%) were, on average, 67.0 years old (min 53, max 91). The majority (69.1%; n = 259) consulted at least one health care practitioner in the previous 12 months for their asthma. Most of the participants (n = 247; 65.9%) reported using at least one prescription medication for asthma in the previous 12 months. The total out-of-pocket expenditure on asthma treatment for Australian women aged 50 years and over is estimated to be AU$159 million per annum. CONCLUSIONS: The breadth of conventional and complementary medicine health care services reported in this study, as well as the range of treatments that patients self-prescribe, highlights the challenges of coordinating care for individuals living with asthma.

Dr Mom's Added Burden.

Today's female physicians face a "triple whammy" of structural discrimination, rigid work expectations, and increasing educational debt. Coronavirus disease 2019 is disproportionately amplifying these forces on women. The burden of these forces on women, the likely long-term consequences, and some preliminary solutions are discussed.

Financial Literacy and Gambling Behavior: Evidence from Japan.

According to a survey by Japan's Ministry of Health, Labor, and Welfare in 2017, 3.6% of Japanese adults-equivalent to about 3.2 million people-have suffered from problem gambling at some point in their lifetime. This study examines the relationship between financial literacy, financial education, and gambling behavior (measured as gambling frequency) among the Japanese population. We hypothesize that financially literate and financially educated people who use their knowledge to make sound financial decisions are less likely to gamble. The data used in this study are from a nationwide survey in Japan from the Preference Parameters Study of Osaka University in 2010 (n = 3687). To control for endogeneity bias between financial literacy and gambling behavior, we use the education of respondents' fathers as an instrumental variable. The results from the probit-instrumental variable model show that financial literacy has a significantly negative relationship with gambling frequency, while financial education has no significant relationship with gambling frequency. Our findings suggest that problem gambling may be mitigated by promoting financial literacy, but no such conclusion can be drawn for financial education.

The effects of coding intensity in Medicare Advantage on plan benefits and finances.

OBJECTIVE: To assess how beneficiary premiums, expected out-of-pocket costs, and plan finances in the Medicare Advantage (MA) market are related to coding intensity. DATA SOURCES/STUDY SETTING: MA plan characteristics and administrative records from the Centers for Medicare and Medicaid Services (CMS) for the sample of beneficiaries enrolled in both MA and Part D between 2008 and 2015. Medicare claims and drug utilization data for Traditional Medicare (TM) beneficiaries were used to calibrate an independent measure of health risk. STUDY DESIGN: Coding intensity was measured by comparing the CMS risk score for each MA contract with a contract level risk score developed using prescription drug data. We conducted regressions of plan outcomes, estimating the relationship between outcomes and coding intensity. To develop prescription drug scores, we assigned therapeutic classes to beneficiaries based on their prescription drug utilization. We then regressed nondrug spending for TM beneficiaries in 2015 on demographic and therapeutic class identifiers for 2014 and used the coefficients to predict relative risk. PRINCIPAL FINDINGS: We found that, for each $1 increase in potential revenue resulting from coding intensity, MA plan bid submissions declined by $0.10 to $0.19, and another $0.21 to $0.45 went toward reducing plans' medical loss ratios, an indication of higher profitability. We found only a small impact on beneficiary's projected out-of-pocket costs in a plan, which serves as a measure of the generosity of plan benefits, and a $0.11 to $0.16 reduction in premiums. As expected, coding intensity's effect on bids was substantially larger in counties with higher levels of MA competition than in less competitive counties. CONCLUSIONS: While coding intensity increases taxpayers' costs of the MA program, enrollees and plans both benefit but with larger gains for plans. The adoption of policies to more completely adjust for coding intensity would likely affect both beneficiaries and plan profits.

Does health insurance protect against risk of financial catastrophe for pancreatic tumor care? A cost-based review of patients undergoing pancreatic resection at an academic institution.

BACKGROUND: Pancreatic cancer is a leading cause of financial insolvency and cancer related deaths in the United States. The risk of catastrophic health expenditure (CHE) was calculated for patients undergoing pancreatic resection at an academic institution. METHODS: Patients who underwent pancreatic resection between 2013 and 2017 were identified through an institutional cancer registry. A CHE was an out-of-pocket payment (OOP) > 10% of the estimated median household income. RESULTS: 319 patients met inclusion criteria. Hospital median charge was $76,700. 99% of patients had insurance and hospital bill adjustments. As a result, 61% (n = 193) made no OOP. Only 3 patients risked CHE. For all tumors combined there were no differences in survival outcomes by OOP. CONCLUSION: This is the first study to use institutional financial data to calculate CHE risk for pancreatic resection patients. Insurance adjustments to hospital charges that accompany health insurance and voluntary hospital adjustments for the uninsured protect patients against CHE.

Willingness to pay for kidney transplantation among chronic kidney disease patients in Ghana.

BACKGROUND: Kidney transplantation is the preferred treatment for patients with end stage renal disease. However, it is largely unavailable in many sub-Sahara African countries including Ghana. In Ghana, treatment for end stage renal disease including transplantation, is usually financed out-of-pocket. As efforts continue to be made to expand the kidney transplantation programme in Ghana, it remains unclear whether patients with Chronic Kidney Disease (CKD) would be willing to pay for a kidney transplant. AIM: The aim of the study was to assess CKD patients' willingness to pay for kidney transplantation as a treatment option for end stage renal disease in Ghana. METHODS: A facility based cross-sectional study conducted at the Renal Outpatient clinic and Dialysis Unit of Korle-Bu Teaching Hospital among 342 CKD patients 18 years and above including those receiving haemodialysis. A consecutive sampling approach was used to recruit patients. Structured questionnaires were administered to obtain information on demographic, socio-economic, knowledge about transplant, perception of transplantation and willingness to pay for transplant. In addition, the INSPIRIT questionnaire was used to assess patients' level of religiosity and spirituality. Contingent valuation method (CVM) method was used to assess willingness to pay (WTP) for kidney transplantation. Logistic regression model was used to determine the significant predictors of WTP. RESULTS: The average age of respondents was 50.2 ± 17.1 years with most (56.7% (194/342) being male. Overall, 90 out of the 342 study participants (26.3%, 95%CI: 21.7-31.3%) were willing to pay for a kidney transplant at the current going price (≥ $ 17,550) or more. The median amount participants were willing to pay below the current price was $986 (IQR: $197 -$1972). Among those willing to accept (67.3%, 230/342), 29.1% (67/230) were willing to pay for kidney transplant at the prevailing price. Wealth quintile, social support in terms of number of family friends one could talk to about personal issues and number of family members one can call on for help were the only factors identified to be significantly predictive of willingness to pay (p-value < 0.05). CONCLUSION: The overall willingness to pay for kidney transplant is low among chronic kidney disease patients attending Korle-Bu Teaching Hospital. Patients with higher socio-economic status and those with more family members one can call on for help were more likely to pay for kidney transplantation. The study's findings give policy makers an understanding of CKD patients circumstances regarding affordability of the medical management of CKD including kidney transplantation. This can help develop pricing models to attain an ideal poise between a cost effective but sustainable kidney transplant programme and improve patient access to this ultimate treatment option.

Assessing the willingness to pay for HIV counselling and testing service: a contingent valuation study in Lagos State, Nigeria.

HIV/AIDS is a major health issue faced by the world, generally, but particularly sub-Saharan Africa. Nigeria ranked third in the world by number of people living with HIV/AIDS in 2019. Despite prominent HIV counselling and testing (HCT) intervention programmes, Nigeria faces serious challenges, such as inadequate funding and low utilisation rates. Paucity of research into such a critical topic has restricted the capacity of policy makers to address the problem adequately. Consequently, a cross-sectional study was carried out using the contingent valuation method to assess the economic quantum of payment and determining factors associated with people's willingness to pay for HCT services. Data were collected from 768 people selected by convenience sampling of three local government areas - Alimosho, Ikorodu and Surulere in Lagos State, Nigeria. Data were analysed using descriptive statistics, chi-square, Mann-Whitney, and general linear regression model analysis. Findings show that 75% of respondents were willing to pay an average fee of N1 291 ($4.22) for HCT services. Significant determinants of willingness to pay were: income; knowledge of someone living with HIV or died of AIDS; worry about HIV infection; and fear of HIV-related stigma. The findings offer vital information germane to co-payment schemes aimed at financial sustainability of HCT and HIV/AIDS programmes in Nigeria.

Assessment of Behavioral Health Services Use Among Low-Income Medicare Beneficiaries After Reductions in Coinsurance Fees.

Importance: Medicare has historically imposed higher beneficiary coinsurance for behavioral health services than for medical and surgical care but gradually introduced parity between 2009 and 2014. Although Medicare insures many people with serious mental illness (SMI), there is limited information on the impact of coinsurance parity in this population. Objective: To examine the association between coinsurance parity and outpatient behavioral health care use among low-income beneficiaries with SMI. Design, Setting, and Participants: This cohort study used Medicare claims data for a 50% national sample of lower-income Medicare beneficiaries from January 1, 2007, to December 31, 2016. The study sample included patients with SMI (schizophrenia, bipolar disorder, or major depressive disorder). Data analysis was performed from August 1, 2018, to July 15, 2020. Exposures: Reduction in behavioral health care coinsurance from 50% to 20% between January 1, 2009, and January 1, 2014. Main Outcomes and Measures: Total annual spending for outpatient behavioral health care visits and the percentage of beneficiaries with an annual outpatient behavioral health care visit overall, with a prescriber, and with a psychiatrist. A difference-in-difference approach was used to compare outcomes before and after the reduction in coinsurance for beneficiaries with and without cost-sharing decreases. Linear regression models with beneficiary fixed effects that adjusted for time-changing beneficiary- and area-level covariates were used to examine changes in outcomes. Results: The study included 793 275 beneficiaries with SMI in 2008; 518 893 (65.4%) were younger than 65 years (mean [SD] age, 57.6 [16.1] years), 511 265 (64.4%) were female, and 552 056 (69.6%) were White. In 2008, the adjusted percentage of beneficiaries with an outpatient behavioral health care visit was 40.7% (95% CI, 40.4%-41.0%) among those eligible for the cost-sharing reduction and 44.9% (95% CI, 44.9%-45.0%) among those with free care. The mean adjusted out-of-pocket costs for outpatient behavioral health care visits decreased from $132 (95% CI, $129-$136) in 2008 to $64 (95% CI, $61-$66) in 2016 among those with reductions in cost-sharing. The adjusted percentage of beneficiaries with behavioral health care visits increased to 42.2% (95% CI, 41.9%-42.5%) in the group with a reduction in coinsurance and to 47.2% (95% CI, 47.0%-47.3%) in the group with free care. The cost-sharing reduction was not positively associated with visits (eg, relative change of -0.76 percentage points [95% CI, -1.12 to -0.40 percentage points] in the percentage of beneficiaries with outpatient behavioral health care visits in 2016 vs 2008). Conclusions and Relevance: This cohort study found that beneficiary costs for outpatient behavioral health care decreased between 2009 and 2014. There was no association between cost-sharing reductions and changes in behavioral health care visits. Low levels of use in this high-need population suggest the need for other policy efforts to address additional barriers to behavioral health care.