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Objective Study Setting and Design Data Sources and Analytical Sample Principal Findings Conclusion To examine differences in access to care and financial burden between Traditional Medicare (TM) and Medicare Advantage (MA) beneficiaries in rural and urban areas and then explore whether there were potential differences in MA benefits between urban and rural areas.We conducted a cross‐sectional study within the Medicare setting in the United States.Data from three distinct sources for 2017–2021: the Medicare Current Beneficiary Survey, the MA landscape data, and the Plan Benefit Package data. Our sample comprised 43,343 Medicare beneficiary‐years, including TM and MA beneficiaries in urban and rural areas.Our adjusted analysis showed that rural MA beneficiaries experienced higher rates of delayed care due to costs (10.0% [95% confidence interval (CI): 8.8–11.1]) compared with rural TM (9.5% [8.8–10.2]), urban MA (7.9% [7.4–8.4]), and urban TM (7.9% [7.5–8.2]) beneficiaries. Similarly, rural MA beneficiaries (11.4% [95% CI: 10.3–12.5]) reported more difficulty paying medical bills compared with rural TM (9.4% [8.7–10.1]), urban MA (8.1% [7.7–8.6]), and urban TM (7.8% [7.5–8.2]) beneficiaries. This disparity was associated with less generous financial structures in rural MA plans. Compared to urban MA plans, rural MA plans offered lower out‐of‐pocket maximums for in‐network care ($5918 vs. $5439), but required higher copayments ($1686 vs. $1724 for a 5‐day hospitalization, $37 vs. $41 for a specialist visit, and $35 vs. $38 for a mental health visit). However, differences in quality of care and provision of supplemental benefits were small.Rural Medicare beneficiaries reported a greater financial burden of care than urban Medicare beneficiaries, but the most significant burden was observed among MA beneficiaries in rural areas. One possible mechanism could be the less generous financial structures offered by rural MA plans. These findings suggest the need for policies addressing the affordability of care for rural MA beneficiaries. [ABSTRACT FROM AUTHOR]

Objective: To examine whether physicians in tiered physician networks where tier assignments are based on "intensity" of care, which is the quantity of resources used per‐episode of care, change their intensity after learning detailed information about how their intensity compares to their peers. Data Sources: Administrative data on intensity and quality at the physician‐episode level for all physicians included in a tiered physician network offered through the Massachusetts Group Insurance Commission (GIC) in 2010–2015. Data on physicians' share of revenue from GIC patients from the 2012 Massachusetts All‐Payer Claims Database. Study Design: For 21,086 physicians in seven specialties, we estimate the impact of the dissemination of detailed intensity performance information in 2014 on physician intensity per episode of care overall and decomposed into physician services, facility, and pharmaceutical subcomponents. Intensity outcomes were measured using a standardized price schedule. Using a difference‐in‐differences regression, we compared physicians with high exposure to the tiered network via a large share of their revenue coming from GIC patients ("GIC share") to physicians who were less exposed. Measures of intensity of care and GIC share were log‐transformed, and models controlled for physician‐episode type fixed effects. Data Extraction Methods: We linked GIC share to administrative data using National Provider Identifier. Principal Findings: There were no statistically significant differences in total intensity of care with the informational intervention for physicians in procedure‐based specialties (−0.12 elasticity of intensity per episode with respect to GIC patient share, 95% CI −0.30 to 0.06) or in relationship‐based specialties (0.09, 95% CI −0.15 to 0.33). There were also no differences in intensity of subcomponents of care following the intervention. Conclusions: Tiered network incentives had no detectable impact on intensity of care that physicians provided to patients. [ABSTRACT FROM AUTHOR]

Prostate cancer treatment in regional Australia is associated with high out-of-pocket costs for patients, with the cost of treatment rising significantly in recent years. Financial toxicity, which refers to the financial burden of a cancer diagnosis on patients and their caregivers, is a significant issue for prostate cancer patients in regional areas. This financial burden can lead to missed appointments, delayed treatment, and poorer health outcomes. Men in rural and regional areas have worse prostate cancer outcomes and are more likely to experience financial barriers to accessing care. A survey conducted in the Grampians region of Victoria found that nearly half of respondents reported a change in employment status following diagnosis, with most reducing work hours or retiring. Ten respondents reported that their financial situation influenced their treatment decisions. However, the study had limitations, including a small sample size and potential response bias. Further research is needed to better understand the financial toxicity experienced by prostate cancer patients in regional Australia and to identify effective ways to address this issue in clinical practice. [Extracted from the article]

Recently, the lengthy waiting time in public hospitals (called the public system) under the free healthcare policy has become a serious problem. To address this issue, motivated by the Japanese healthcare system, this paper investigates a two‐tier co‐payment healthcare system under a uniform pricing and subsidy coordination mechanism. In such a setting, the public system and the private system (i.e., the private hospitals) compete for market share with different objectives, whereas the government uniformly sets the service price and the subsidy rate to maximize social welfare under a total budget constraint. Compared with two free healthcare policy cases implemented in the Canadian and Australian healthcare systems respectively in terms of social welfare, the results show that when the market demand (or the patient service quality sensitivity) is sufficiently high (sufficiently low), the uniform pricing and subsidy coordination mechanism is better and worse otherwise; and when the patient's waiting sensitivity (or the total government budget) is in an appropriate middle range (sufficiently low or high), the mechanism can outperform than the free policy cases. [ABSTRACT FROM AUTHOR]

Objective: HIV (human immunodeficiency virus) infection remains a major public health challenge. Infected young people at any age are less likely to adhere to care in a timely manner and to maintain a suppressed VL. This review aims to identify factors associated with virologic failure and adherence to drug therapy in adolescents and young adults (10–24 years) living with HIV. Methods: Systematic review using the PubMed and Virtual Health Library databases and including articles published between 2009 and 2021. Data were analysed in six categories: individual factors, pharmacological/therapy‐related aspects, factors related to HIV/acquired immunodeficiency syndrome (AIDS) infection, HIV/AIDS stigma, social support and health system/services. The study's protocol was registered on the PROSPERO platform (CRD42020167581). Results: A total of 19,819 articles were found in the initial search and 31 studies were included in this systematic review. Most studies were carried out on the African continent. Male sex, alcohol use, low education, adverse effects of medication, lack of social support, stigma related to HIV/AIDS, need for transportation to access the health service and forgetfulness were linked to poor adherence to therapy. Good adherence was achieved with sufficient nutrition, good social support, greater confidence in the use of therapy and fewer ART side effects. Low levels of CD4, alcohol use, substance abuse, low education, non‐adherence to medication and forgetfulness were linked to virological failure. Conclusion: Individual, social and structural factors constitute barriers to adherence to ART among adolescent and young adults. It is necessary to know the difficulties related to the use of therapy to work out specific strategies that create conditions to improve medication adherence and viral suppression, reducing the levels of virological failure in this population. [ABSTRACT FROM AUTHOR]

Objective: To determine if greater non‐profit hospital spending for community benefits is associated with better health outcomes in the county where they are located. Data Sources and Study Setting: Community benefit data from IRS Form 990/Schedule H was linked to health outcome data from Area Health Resource Files, Map the Meal Gap, and Medicare claims from the Center for Medicare and Medicaid Services at the county level. Counties with at least one non‐profit hospital in the United States from 2015 to 2019 (N = 5469 across the 5 years) were included. Study Design: We ran multiple regressions on community benefit expenditures linked with the number of health professionals, food insecurity, and adherence to diabetes and hypertension medication for each county. Data Collection: The three outcomes were chosen based on prior studies of community benefit and a recent survey sent to 12 health care executives across four regions of the U.S. Data on community benefit expenditures and health outcomes were aggregated at the county level. Principal Findings: Average hospital community benefit spending in 2019 was $63.6 million per county ($255 per capita). Multivariable regression results did not demonstrate significant associations of total community benefit spending with food insecurity or medication adherence for diabetes. Statistically significant associations with the number of health professionals per 1000 (coefficient, 12.10; SE, 0.32; p < 0.001) and medication adherence for hypertension (marginal effect, 0.27; SE, 0.09; p = 0.003) were identified, but both would require very large increases in community benefit spending to meaningfully improve outcomes. Conclusions: Despite varying levels of non‐profit hospital community benefit investment across counties, higher community benefit expenditures are not associated with an improvement in the selected health outcomes at the county level. Hospitals can use this information to reassess community benefit strategies, while federal, state, and local governments can use these findings to redefine the measures of community benefit they use to monitor and grant tax exemption. [ABSTRACT FROM AUTHOR]

Medicaid and the Children's Health Insurance Program (CHIP) both combine federal mandates to cover certain services and groups with state options in providing that coverage and in covering other services and groups. Using state‐level panel data, we investigated the relationships of 83 state Medicaid and CHIP options with six child health outcomes from 2001 to 2018 using structural equation modeling, controlling for 10 possible demographic and economic variables, state fixed effects, and a quadratic year count variable. Our results suggest that reducing copayments and providing express eligibility may be especially important in improving child health outcomes; eliminating or reducing waiting periods, eliminating face‐to‐face interview requirements, and eliminating documentation requirements may also be helpful. Other state options that have been found to be important in improving child insurance outcomes, such as eliminating asset tests and providing continuous eligibility, were not as helpful for improving child health outcomes in our results. Key points: Reducing copayments and providing express eligibility for coverage under Medicaid and the Children's Health Insurance Program may have been especially important in improving child health outcomes in the United States from 2008 to 2018.Eliminating or reducing waiting periods, eliminating face‐to‐face interview requirements, and eliminating documentation requirements for coverage may also have helped to improve child health outcomes.Other state options that have been found to be important in improving child insurance outcomes, such as eliminating asset tests and providing continuous eligibility, may have been less important for child health outcomes. [ABSTRACT FROM AUTHOR]

Objective: Underrepresented racial and ethnic minorities are disproportionately affected by systemic lupus erythematosus (SLE). Racial and ethnic minorities also have more severe SLE manifestations that require use of immunosuppressive medications, and often have lower rates of medication adherence. We aimed to explore barriers of adherence to SLE immunosuppressive medications among minority SLE patients. Methods: We conducted a qualitative descriptive study using in‐depth interviews with a purposive sample of racial minority SLE patients taking oral immunosuppressants (methotrexate, azathioprine, or mycophenolate), and lupus clinic providers and staff. Interviews were audiorecorded, transcribed, and analyzed using applied thematic analysis. We grouped themes using the Capability, Opportunity, Motivation, Behavior conceptual model. Results: We interviewed 12 SLE patients (4 adherent, 8 nonadherent) and 12 providers and staff. We identified capability barriers to include external factors related to acquiring medications, specifically cost‐, pharmacy‐, and clinic‐related issues; opportunity barriers to include external barriers to taking medications, specifically logistic‐ and medication‐related issues; and motivation factors to include intrinsic barriers, encompassing patients' knowledge, beliefs, attitudes, and physical and mental health. The most frequently described barriers were cost, side effects, busyness/forgetting, and lack of understanding, although barriers differed by patient and adherence level, with logistic and intrinsic barriers described predominantly by nonadherent patients and side effects described predominantly by adherent patients. Conclusion: Our findings suggest that interventions may be most impactful if they are designed to facilitate logistics of taking medications and increase patients' motivation while allowing for personalization to address the individual differences in adherence barriers. [ABSTRACT FROM AUTHOR]

Background: Individuals with spinal cord injuries and disorders (SCI/D) require frequent interdisciplinary health care to address impairments in mobility, autonomic function, and secondary complications. Telehealth has the capacity to substantially transform health care delivery and improve care by increasing access and communication. However, relatively little is known about telehealth use in this specific population. Here we attempt to fill part of this gap. Objective: To investigate the frequency and characteristics associated with telehealth use in Veterans with SCI/D. Design: Cross‐sectional, descriptive project. Setting: Veterans Health Administration (VHA) facilities. Participants: A total of 15 028 Veterans living with SCI/D who received services from the VHA SCI/D System of Care. Intervention: Not applicable. Outcome Measures: Frequency and characteristics associated with VHA telehealth utilization. Results: Of the 15 028 Veterans with SCI/D included in the evaluation, 17% used some form of telehealth in VHA Fiscal Year (FY)2017. Veterans older than 65 years of age had lower odds (odds ratio [OR] = 0.88, P <.05, confidence interval [CI] 0.80‐0.98) of using telehealth. Being Caucasian (OR = 1.29, P <.01, CI 1.09‐1.52), living in rural areas (OR = 1.16, P <.01, CI 1.05‐1.28), living greater distances away from the VHA (P <.01 for all distances), and being in priority group 8, meaning that Veterans have higher copayment requirements (OR = 1.46, P <.001, CI 1.19‐1.81), were all significantly associated with greater odds of telehealth use. The most frequent types of telehealth used were real‐time clinical video and store‐and‐forward between a provider and patient within the same hub network. Conclusion: There are opportunities to increase telehealth adoption in the SCI/D arena. The findings from this project highlight which Veterans are currently using telehealth services, as well as gaps regarding telehealth adoption in this population. [ABSTRACT FROM AUTHOR]

The Final Report of the Royal Commission into Aged Care Quality and Safety (Commonwealth of Australia 2021) highlighted the challenges in developing a sustainable financing system for aged care in Australia. The report recommended additional funding both in the short term and longer term so as to provide an adequate level of aged care quality for older Australians, including exploring an actuarially based contributory social insurance scheme for aged care. Sustainable financing of aged care requires a balance between government tax‐based financing, individual contributions during working life through an aged care levy, copayments for aged care costs for those receiving aged care and means testing for these copayments. There should be a role for private market insurance and financing to supplement government financed aged care support. [ABSTRACT FROM AUTHOR]

Objective: To test the effectiveness of physician incentives for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins.Data Sources: Pharmacy and medical claims from a large Medicare Advantage Prescription Drug Plan from January 2011 to December 2012.Study Design: We conducted a randomized experiment (911 primary care practices and 8,935 nonadherent patients) to test the effect of paying physicians for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins. We measured patients' medication adherence for 18 (6) months before (after) the intervention.Data Collection/extraction Methods: We obtained data directly from the health insurer.Principal Findings: We found no evidence that physician incentives increased adherence in any drug class. Our results rule out increases in the proportion of days covered by medication larger than 4.2 percentage points.Conclusions: Physician incentives of $50 per patient per drug class are not effective for increasing patient medication adherence among the drug classes and primary care practices studied. Such incentives may be more likely to improve measures under physicians' direct control rather than those that predominantly reflect patient behaviors. Additional research is warranted to disentangle whether physician effort is not responsive to these types of incentives, or medication adherence is not responsive to physician effort. Our results suggest that significant changes in the incentive amount or program design may be necessary to produce responses from physicians or patients. [ABSTRACT FROM AUTHOR]

Background: Adherence to endocrine therapy for breast cancer is often inadequate, in part because of out-of-pocket costs for medication. Numerous states have enacted parity laws to limit patient cost-sharing for oral anticancer drugs. The objective of this study was to estimate the impact of these laws on patient copayments for and adherence to oral endocrine therapy for breast cancer.Methods: Administrative health insurance claims data from 2007 to 2014 derived from a US health care database were used to identify female patients aged 18 to 64 years with invasive cancer or ductal carcinoma in situ of the breast who initiated endocrine therapy and were enrolled in fully insured health plans in states that either enacted parity legislation between 2008 and 2013 or had not yet enacted such legislation by 2015. Differences-in-differences analysis was used to compare copayments for and adherence to endocrine therapy during the 1-year period before and after each year of legislation enactment.Results: In total, 6900 individuals who received 7778 unique drug therapy courses were identified. Parity legislation was associated with significant decreases in the 25th percentile of copayments for anastrozole of $4.39 (95% confidence interval [CI], -$4.52 to -$4.26; P < .001) and for exemestane of $3.08 (95% CI, -$4.80 to -$1.35; P < .001). The median copayment for exemestane decreased by $10.25 (95% CI, -$12.61 to -$7.89; P < .001). A higher median monthly copayment was significantly associated with a greater risk of medication nonadherence (adjusted risk ratio, 1.006 per dollar increase; P < .001).Conclusions: Parity laws had a modest effect on lowering the cost of anastrozole and exemestane, but more focused efforts to limit out-of-pocket costs for endocrine therapy may have a greater impact on medication adherence. [ABSTRACT FROM AUTHOR]

In the current issue the article by Kong et al1 titled "Do Physician Incentives Increase Patient Medication Adherence" addresses the role of physician incentives in encouraging physicians to counsel patients to improve adherence to important medications for chronic conditions including diabetes medications, antihypertensive medications, and statins. The authors conclude that physician incentives of "$50 per drug class are not effective for increasing patient medication adherence among the drug classes and primary care practices studied (Abstract)". The intervention focused on physicians treating patients who were nonadherent to medications in at least one of the three medication classes (diabetes medications, antihypertensive medications, and statins). [Extracted from the article]

Abstract: This paper studies the consequences of parallel trade in a two‐country model. It compares a coinsurance scheme (consumers pay a percentage of the drug price) and an indemnity insurance scheme (reimbursement is independent of the drug price) with respect to changes in copayments and public health expenditure. In the destination country, copayments for patients decrease to a larger extent under indemnity insurance, whereas reductions in public health expenditure occur only under coinsurance. In the source country, copayments increase less under coinsurance, whereas health expenditure is reduced more under indemnity insurance. In both countries, total expenditure under parallel trade is lower. [ABSTRACT FROM AUTHOR]

In this paper, we re-examine the properties of two commonly adopted government reimbursement schemes for pharmaceuticals: reference pricing and fixed percentage reimbursement. We depart from the previous literature by assuming that the individual demand is price-sensitive and depends on the copayment rate (i.e., the part paid by each consumer). We obtain two novel results under reference pricing: first, as the copayment rate increases, so do pharmaceutical prices; second, this increase in pharmaceutical prices reduces social welfare. Whilst reference pricing does emerge as a preferable reimbursement scheme, demand elasticities and the copayment rate interact in complex ways. This leads (unexpectedly) to the possibility that a higher copayment rate (lower reimbursement rate) results in higher government expenditure. [ABSTRACT FROM AUTHOR]

Expanding access through insurance expansion can increase health-care utilization through moral hazard. Reforming provider incentives to introduce more supply-side cost sharing is increasingly viewed as crucial for affordable, sustainable access. Using both difference-in-differences and segmented regression analyses on a panel of 1,466 hypertensive and diabetic patients, we empirically examine Shandong province's initial implementation of China's 2009 Essential Medications List policy. The policy reduced drug sale markups to providers but also increased drug coverage benefits for patients. We find that providers appeared to compensate for lost drug revenues by increasing office visits, for which no fee reduction occurred. At the same time, physician agency (yielding to patient demand for pharmaceuticals) may have tempered provider incentives to reduce drug expenditures at the visit level. Taken together, the policy may have increased total spending or total out-of-pocket expenditures. Mandating payment reductions in a service that comprises a large portion of provider income may have unintended consequences. [ABSTRACT FROM AUTHOR]

The article presents a study which aims to assess the effect of general practitioners' (GP) income in the indexation freeze and rebate reduction of Medicare fees in Australia. Information related to the required copayment for GPs, rebate income loss, and number of patient consultations, are discussed.

Objective To examine how enrollees' statin compliance responds to expected prices in Medicare Part D, which features a nonlinear price schedule due to a coverage gap. Data Sources/Study Setting Prescription Drug Event data for a 5 percent random sample of Medicare Advantage Prescription Drug Plan enrollees in 2008 who did not receive a low-income subsidy. Study Design We analyze statin compliance prior to the coverage gap, where the 'effective price' is higher than the actual copayment for drugs because consumers anticipate that more spending will make them more likely to reach the gap. We construct each enrollee's effective price as her expected price at the end of the year, which is the weighted average between pre-gap and in-gap copayments with the weight being the predicted probability of hitting the gap. Compliance is defined as at least 80 percent of days covered. Principal Findings Part D enrollees' pre-gap statin compliance decreases by 3.7-4.7 percentage points for a $10 increase in the effective price. Conclusion The presence of a coverage gap decreases statin compliance prior to the gap, suggesting that incorporating expected future prices is important to assess the full impact of cost sharing on drug compliance under nonlinear price schedules. [ABSTRACT FROM AUTHOR]

Objective The reliability of general self-rated health status is examined using the reform of the public health insurance system of Germany in 2004 as a source of exogenous variation. The reform introduced a co-payment for ambulatory doctor visits and increased the co-payments for prescription drugs. Methods This natural experiment allows identification of the causal impact of the program on self-assessed health (SAH). A difference-in-differences estimator is applied to estimate the effect of the reform on SAH. Results Using data from the German Socio-Economic Panel, the results indicate that the reform improved the treatment group's average SAH even when there was no discernible impact on actual health. Conclusion The exercise reveals the sensitivity of SAH to a perturbation in the insurance system. More objective measures of health may be needed to acquire an accurate assessment of general health when the health system is in flux. [ABSTRACT FROM AUTHOR]

B This article refers to 'The Heart Failure Association Atlas: Heart Failure Epidemiology and Management Statistics 2019' by P.M. Seferovi'c I et al i ., published in this issue on pages 906-914. b ' Many of the things you can count, don't count. The Heart Failure Association Atlas: Heart Failure Epidemiology and Management Statistics 2019. [Extracted from the article]

Purpose We examined how the choice of historic medication use criteria for identifying prevalent users may bias estimated adherence changes associated with a medication copayment increase. Methods From pharmacy claims data in a retrospective cohort study, we identified 6,383 prevalent users of oral diabetes medications from four VA Medical Centers. Patients were included in this prevalent cohort if they had one fill both 3 months prior and 4-12 months prior to the index date, defined as the month in which medication copayments increased. To determine whether these historic medication use criteria introduced bias in the estimated response to a $5 medication copayment increase, we compared adherence trends from cohorts defined from different medication use criteria and from different index dates of copayment change. In an attempt to validate the prior observation of an upward trend in adherence prior to the date of the policy change, we replicated time series analyses varying the index dates prior to and following the date of the policy change, hypothesizing that the trend line associated with the policy change would differ from the trend lines that were not. Results Medication adherence trends differed when different medication use criteria were applied. Contrary to our expectations, similar adherence trends were observed when the same medication use criteria were applied at index dates when no copayment changes occurred. Conclusion To avoid introducing bias due to study design in outcomes assessments of medication policy changes, historic medication use inclusion criteria must be chosen carefully when constructing cohorts of prevalent users. Furthermore, while pharmacy data have enormous potential for population research and monitoring, there may be inherent logical flaws that limit cohort identification solely through administrative pharmacy records. [ABSTRACT FROM AUTHOR]

Objective To explore whether health care utilization changed among enrollees in Alabama's CHIP program, ALL Kids, following copayment increases at the beginning of fiscal year 2004. Data Sources Data on all ALL Kids enrollees over 1999-2009 are obtained from claims files and the state's administrative database. Study Design We use pooled month-level data for all enrollees and conduct covariate-adjusted segmented regression models. Health services considered are inpatient care, emergency department ( ED) visits, brand-name prescription drugs, generic prescription drugs, physician office visits and outpatient-services, ambulance services, allergy treatments, and non-preventive dental services. Physician well-visits, preventive dental services, and service use by Native-Americans-which saw no copayment increases-serve as counterfactuals. Principal Findings There are significant declines in utilization for inpatient care, physician visits, brand-name medications, and ED visits following the copayment increases. By and large, utilization did not decline, or declined only temporarily, for those services and for those enrollees that who not subject to increased copayments. Conclusions Copayment increases reduced utilization of many health services among ALL Kids enrollees. Concerns remain regarding the long-term health consequences to low-income children of copayment-induced reductions in health care utilization. [ABSTRACT FROM AUTHOR]

Objectives. To compare changes in medication adherence between patients with high- or low-comorbidity burden after a copayment increase. Methods. We conducted a retrospective observational study at four Veterans Affairs (VA) medical centers by comparing veterans with hypertension or diabetes required to pay copayments with propensity score-matched veterans exempt from copayments. Disease cohorts were stratified by Diagnostic Cost Group risk score: low- (<1) and high-comorbidity (>1) burden. Medication adherence from February 2001 to December 2003, constructed from VA pharmacy claims data based on the ReComp algorithm, were assessed using generalized estimating equations. Results. Veterans with lower comorbidity were more responsive to a U.S.$5 copayment increase than higher comorbidity veterans. In the lower comorbidity groups, veterans with diabetes had a greater reduction in adherence than veterans with hypertension. Adherence trends were similar for copayment-exempt and nonexempt veterans with higher comorbidity. Conclusion. Medication copayment increases are associated with different impacts for low- and high-risk patients. High-risk patients incur greater out-of-pocket costs from continued adherence, while low-risk patients put themselves at increased risk for adverse health events due to greater nonadherence. [ABSTRACT FROM AUTHOR]

To estimate the effect of two separate policy changes in the North Carolina Medicaid program: (1) reduced prescription lengths from 100 to 34 days' supply, and (2) increased copayments for brand name medications. Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000-December 31, 2002. We used a pre-post controlled partial difference-in-difference-in-differences design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures. Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant, or deceased in the quarter were excluded. Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy, but the copayment policy resulted in a net increase in Medicaid expenditures. Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees. [ABSTRACT FROM AUTHOR]

To assess how quality information from multiple sources and financial incentives affect consumer choice of physicians in tiered physician networks. Survey of a stratified random sample of Massachusetts state employees. Respondents were assigned a hypothetical structure with differential copayments for 'Tier 1' (preferred) and 'Tier 2' (nonpreferred) physicians. Half of respondents were told they needed to select a cardiologist, and half were told they needed to select a dermatologist. Patients were asked whether they would choose a Tier 1 doctor, a Tier 2 doctor, or had no preference in a case where they had no further quality information, a case where a family member or friend recommended a Tier 2 doctor, and a case where their personal physician recommended a Tier 2 doctor. The effects of copayments, recommendations, physician specialty, and patient characteristics on the reported probability of selecting a Tier 1 doctor are analyzed using multinomial logit and logistic regression. Relative to a case where there is no copayment differential between tiers, copayment differences of U.S.$10-U.S.$35 increase the number of respondents indicating they would select a Tier 1 physician by 3.5-11.7 percent. Simulations suggest copayments must exceed U.S.$300 to counteract the recommendation for a lower tiered physician from friends, family, or a referring physician. Sensitivity to the copayments varied with physician specialty. Tiered provider networks with these copayment levels appear to have limited influence on physician choice when contradicted by other trusted sources. Consumers' response likely varies with physician specialty. [ABSTRACT FROM AUTHOR]

Objective. To explore obstetricians' opinions on cesarean section (CS) on maternal request in the absence of a medical indication, and the potential to regulate CS on maternal request through financial incentives such as patient co-payment. Design. Cross-sectional study. Setting. Norway. Population/sample: A total of 507 obstetricians (response rate 71%). Methods. Questionnaire covering socio-demographic variables, professional experience and attitudes about CS on maternal request (such as willingness to perform, views on how CS on maternal request should be financed). Main outcome measures. Obstetricians' opinions about CS on maternal request including funding and use of patient co-payments. Results. Clinical encounters with CS on maternal request were considered problematic from a clinical viewpoint by 62% of the respondents. While 35% considered the costs of CS on maternal request to be a public responsibility, 40% suggested use of co-payments ranging from €188- €7,500. Male obstetricians less frequently considered CS on maternal request problematic and were more likely to favor public funding than females. Female obstetricians favored use of co-payments more often than males (64% female vs. 37% male obstetricians, χ2 = 23.94, p < 0.001) and suggested higher co-payments. The median co-payment was €1,875 for female and €1,250 for male obstetricians ( p < 0.001). Conclusions. The study supports the existence of a gender difference concerning obstetricians' responses to patient requested cesarean section. The results indicate that a substantial proportion of obstetricians welcome some form of constraint concerning cesarean section requests in the absence of a medical indication. [ABSTRACT FROM AUTHOR]

Insurance for prescription drugs is characterized by two types of cost-sharing: flat copayments and variable coinsurance. We develop a theoretical model to show that refill purchases of drugs are lower under coinsurance due to the consumer’s exposure to variation in drug prices. We test this empirically using claims data from eight large firms. Propensity score methods are used to create matched samples for the two insurance regimes. We find that when coinsurance and copayments have the same expected out-of-pocket of $9, at least 34% of patients under copayments would fully refill their medication over 90 days, compared to only 24% under coinsurance. [ABSTRACT FROM AUTHOR]

Objective. To estimate the impact of a soft cap (a ceiling on utilization beyond which insured enrollees pay a higher copayment) on low-income elders' use of prescription drugs. Data Sources and Setting. Claims and enrollment files for the first year ( June 2002 through May 2003) of the Illinois SeniorCare program, a state pharmacy assistance program, and Medicare claims and enrollment files, 2001 through 2003. SeniorCare enrolled non-Medicaid-eligible elders with income less than 200 percent of Federal Poverty Level. Minimal copays increased by 20 percent of prescription cost when enrollee expenditures reached $1,750. Research Design. Models were estimated for three dependent variables: enrollees' average monthly utilization (number of prescriptions), spending, and the proportion of drugs that were generic rather than brand. Observations included all program enrollees who exceeded the cap and covered two periods, before and after the cap was exceeded. Principle Findings. On average, enrollees exceeding the cap reduced the number of drugs they purchased by 14 percent, monthly expenditures decreased by 19 percent, and the proportion generic increased by 4 percent, all significant at p<.01. Impacts were greater for enrollees with greater initial spending, for enrollees without one of five chronic illness diagnoses in the previous calendar year, and for enrollees with lower income. Conclusions. Near-poor elders enrolled in plans with caps or coverage gaps, including Part D plans, may face sharp declines in utilization when they exceed these thresholds. [ABSTRACT FROM AUTHOR]

Objectives. To determine the impact of introducing copayments on medical care use and expenditures for low-income, adult Medicaid beneficiaries. Data Sources/Study Setting. The Oregon Health Plan (OHP) implemented copayments and other benefit changes for some adult beneficiaries in February 2003. Study Design. Copayment effects were measured as the “difference-in-difference” in average monthly service use and expenditures among cohorts of OHP Standard (intervention) and Plus (comparison) beneficiaries. Data Collection/Extraction Methods. There were 10,176 OHP Standard and 10,319 Plus propensity score-matched subjects enrolled during November 2001–October 2002 and May 2003–April 2004 that were selected and assigned to 59 primary care-based service areas with aggregate outcomes calculated in six month intervals yielding 472 observations. Results. Total expenditures per person remained unchanged (+2.2 percent, p=.47) despite reductions in use (−2.7 percent, p<.001). Use and expenditures per person decreased for pharmacy (−2.2 percent, p<.001; −10.5 percent, p<.001) but increased for inpatient (+27.3 percent, p<.001; +20.1 percent, p=.03) and hospital outpatient services (+13.5 percent, p<.001; +19.7 percent, p<.001). Ambulatory professional (−7.7 percent, p<.001) and emergency department (−7.9 percent, p=.03) use decreased, yet expenditures remained unchanged (−1.5 percent, p=.75; −2.0 percent, p=.68, respectively) as expenditures per service user rose (+6.6 percent, p=.13; +7.9 percent, p=.03, respectively). Conclusions. In the Oregon Medicaid program applying copayments shifted treatment patterns but did not provide expected savings. Policy makers should use caution in applying copayments to low-income Medicaid beneficiaries. [ABSTRACT FROM AUTHOR]

Objectives. To assess the impact of multitiered copayments on the cost and use of prescription drugs among Medicare beneficiaries. Data Sources. Marketscan 2002 Medicare Supplemental and Coordination of Benefits database and Plan Benefit Design database. Study Design. The study uses cross-sectional variation in copayment structures among firms with a self-insured retiree health plan to measure the impact of number of copayment tiers on total and enrollee drug payments, number of prescriptions filled, and generic substitution. The study also assesses the effect of enrollee cost sharing on the cost and use of prescription medications for the long-term treatment of chronic conditions. Data Collection Methods. We linked plan enrollment and benefit data with medical and drug claims for 352,760 Medicare beneficiaries with employer-sponsored retiree drug coverage. Primary Findings. Medicare beneficiaries in three-tiered plans had 14.3 percent lower total drug expenditures, 14.6 percent fewer prescriptions filled, and 57.6 percent higher out-of-pocket costs than individuals in lower tiered plans. They also had fewer brand name and generic prescriptions filled, and a higher percentage of generics. The estimated price elasticity of demand for prescription drug expenditures was −0.23. Finally, for maintenance medications used for the long-term treatment of chronic conditions, members in three-tiered plans had 11.5 percent fewer prescriptions filled. Conclusions. Higher tiered drug plans reduce overall expenditures and the number of prescriptions purchased by Medicare beneficiaries. Beneficiaries are less responsive to cost sharing incentives when using drugs to treat chronic conditions. [ABSTRACT FROM AUTHOR]

Objective. Assess patient knowledge of and response to drug cost sharing. Study Setting. Adult members of a large prepaid, integrated delivery system. Study Design/Data Collection. Telephone interviews with 932 participants (72 percent response rate) who reported knowledge of the structures and amounts of their prescription drug cost sharing. Participants reported cost-related changes in their drug adherence, any financial burden, and other cost-coping behaviors. Actual cost sharing amounts came from administrative databases. Principal Findings. Overall, 27 percent of patients knew all of their drug cost sharing structures and amounts. After adjustment for individual characteristics, additional patient cost sharing structures (tiers and caps), and higher copayment amounts were associated with reporting decreased adherence, financial burden, or other cost-coping behaviors. Conclusions. Patient knowledge of their drug benefits is limited, especially for more complex cost sharing structures. Patients also report a range of responses to greater cost sharing, including decreasing adherence. [ABSTRACT FROM AUTHOR]

Objective. To evaluate the effect of emergency department (ED) copayment levels on ED use and unfavorable clinical events. Data Source/Study Setting. Kaiser Permanente–Northern California (KPNC), a prepaid integrated delivery system. Study Design. In a quasi-experimental longitudinal study with concurrent controls, we estimated rates of ED visits, hospitalizations, ICU admissions, and deaths associated with higher ED copayments relative to no copayment, using Poisson random effects and proportional hazard models, controlling for patient characteristics. The study period began in January 1999; more than half of the population experienced an employer-chosen increase in their ED copayment in January 2000. Data Collection/Extraction Methods. Using KPNC automated databases, the 2000 U.S. Census, and California state death certificates, we collected data on ED visits and unfavorable clinical events over a 36-month period (January 1999 through December 2001) among 2,257,445 commercially insured and 261,091 Medicare insured health system members. Principal Findings. Among commercially insured subjects, ED visits decreased 12 percent with the $20–35 copayment (95 percent confidence interval [CI]: 11–13 percent), and 23 percent with the $50–100 copayment (95 percent CI: 23–24 percent) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not increase with copayments. Hospitalizations decreased 4 percent (95 percent CI: 2–6 percent) and 10 percent (95 percent CI: 7–13 percent) with ED copayments of $20–35 and $50–100, respectively, compared with no copayment. Among Medicare subjects, ED visits decreased by 4 percent (95 percent CI: 3–6 percent) with the $20–50 copayments compared with no copayment; unfavorable clinical events did not increase with copayments, e.g., hospitalizations were unchanged (95 percent CI: −3 percent to +2 percent) with $20–50 ED copayments compared with no copayment. Conclusions. Relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events. [ABSTRACT FROM AUTHOR]

Aim. This paper reports a study exploring willingness to use home care nursing services among older people and discussing the implications for long-term and home care nursing policies. Background. The proportion of older people is increasing in all societies across the world. Correspondingly, Korean society has experienced a rapid growth in its population of older people, and this is expected to increase from 7.2% in 2000 to 14.4% in 2019. The government is in the process of developing publicly-financed long-term care for older people, and home care nursing services are expected to be provided as an element of this care. Methods. A cross-sectional study design was used, employing data from a nationally representative interview survey with 1834 respondents conducted during May and July, 2001. Univariate and logistic regression analyses were conducted. Results. Willingness to use home care nursing services differed according to whether co-payment was required. About half the respondents answered that they would not use the services; 43% expressed a willingness to use them without co-payment; and 5% were very willing to use them even with co-payment. People with lower incomes showed greater willingness to use the services with no co-payment, while the high income group showed the greatest willingness under co-payment. Sex, living with adult children, living area, activities of daily living, and chronic conditions were associated with willingness. Older people who had known about or used home care nursing services previously showed greater willingness. Conclusions. Co-payment guidelines for minimizing unmet needs are required, especially for older people with low incomes. A positive evaluation from those who knew about or had used such services is expected to contribute to the use of home care nursing services by older people. [ABSTRACT FROM AUTHOR]

In response to falling rates of bulk billing, in April 2003 the Australian Government proposed changes to the way that general practitioners (GPs) are reimbursed. It claimed that the General Practice Access Scheme (GPAS) would benefit all Australians by providing more affordable access to GP services and improved access to free GP consultations for concession cardholders. This article examines the likely impacts of the GPAS, focusing on the proposed changes to bulk billing and payments to GPs. It examines the current spatial distribution of bulk billing and discusses how the package changes the incentives for GPs to charge patients and likely impacts on GP income, patient copayments and bulk billing rates. [ABSTRACT FROM AUTHOR]

If an illness is not contractible, then even partially insured consumers demand treatment for it when the benefit is less than the cost, a condition known as moral hazard. Traditional health insurance, which controls moral hazard with copayments (demand management), can result in either a deficient or an excessive provision of treatment relative to ideal insurance. In particular, treatment for a low-probability illness is deficient if illness per se has little effect on the consumer's marginal utility of income and if the consumer's price elasticity of expected demand for treatment is large relative to the risk-spreading distortion when these are evaluated at a copayment that brings forth the ideal provision of treatment. Managed care, which controls moral hazard with physician incentives, can either increase or decrease treatment delivery relative to traditional insurance, depending on whether demand management results in deficient or excessive treatment. [ABSTRACT FROM AUTHOR]

Presents an analysis of the effect of the implementation of per-visit copayment for medical services in Korea. Effectiveness of the introduction of per-visit copayment; Changes after the implementation of the copayment.

This article assesses the effects of economic condition and the factors affecting insurance coverage. Three alternatives have been proposed as solutions to the problems arising with full coverage: co-insurance, deductibles and limits of coverage. All of these solutions require the insured to pay some portion of the goods' price. While co-insurance and deductibles have been frequently examined, both theoretically and empirically, limits of coverage have not been widely considered as a solution to the resource misallocation problem.

This article focuses on cost containment and initiation of care for cancer in a medicare-eligible population. Providing quality health care to the elderly while containing costs has become a key policy dilemma for the Social Security system. To contain costs, the federal government has often considered encouraging medicare beneficiaries to join Health Maintenance Organizations (HMOs) and requiring them to pay a higher percentage of the charges for their care. Supporters of HMOs argue that these organizations, free from the temptation in fee-for-service settings to provide more services than necessary, deliver care more economically. Investigations in both the United States and Canada indicate that copayment significantly reduces utilization of services, while a broad range of research studies suggests that lack of disposable income and inadequate insurance coverage cause at least some individuals to forego necessary care. These findings raise issues about possible impacts of recent cost-containment proposals on the quality of care received by Medicare beneficiaries with limited resources and progressive, life-threatening illnesses.

Comments on the 2005-2006 Australian budget and its impact on the availability and affordability of prescription medicines. Increase in prescription copayment for general users; Factor that contributed to the slowed growth in Pharmaceutical Benefits Scheme expenditure for 2004-2005; Critique of the government's policy on pharmaceutical industry prices.

Introduction: The success of universal antiretroviral therapy (ART) access and aspirations for an AIDS‐free generation depend on high adherence in individuals initiating ART during early‐stage HIV infection; however, adherence may be difficult in the absence of illness and associated support. Methods: From March 2015 to October 2017, we prospectively observed three groups initiating ART in routine care in Uganda and South Africa: men and non‐pregnant women with early‐stage HIV infection (CD4 > 350 cells/μL), pregnant women with early‐stage HIV infection and men and non‐pregnant women with late‐stage HIV infection (CD4 < 200 cells/μL). Socio‐behavioural questionnaires were administered and viral loads were performed at 0, 6 and 12 months. Adherence was monitored electronically. Results: Adherence data were available for 869 participants: 322 (37%) early/non‐pregnant, 199 (23%) early/pregnant and 348 (40%) late/non‐pregnant participants. In Uganda, median adherence was 89% (interquartile range 74 to 96) and viral suppression was 90% at 12 months; neither differed among groups (p > 0.72). In South Africa, median adherence was higher in early/non‐pregnant versus early/pregnant or late/non‐pregnant participants (76%, 37%, 52%; p < 0.001), with similar trends in viral suppression (86%, 51%, 79%; p < 0.001). Among early/non‐pregnant individuals in Uganda, adherence was higher with increasing age and lower with structural barriers; whereas in South Africa, adherence was higher with regular income, higher perceived stigma and use of other medications, but lower with maladaptive coping and cigarette smoking. Discussion: ART adherence among non‐pregnant individuals with early‐stage infection is as high or higher than with late‐stage initiation, supporting universal access to ART. Challenges remain for some pregnant women and individuals with late‐stage infection in South Africa and highlight the need for differentiated care delivery. [ABSTRACT FROM AUTHOR]

The article discusses the proposal of the Australian government as of February 2015 to introduce a copayment for visits to general practitioners. Topics include longer term consequences of the copayment, impact on affordability and access to health care, and impact of co-payments on the longer term health outcomes of consumers.

A letter to the editor in response to the editorial "Copayments for general practice visits" by CB DelMar, published in the 2014 issue of the journal and its response from the author of the article is presented.

The article focuses on the benefits of the U.S. Patient Protection and Affordable Care Act (ACA) for cancer patients and survivors. It mentions that the ACA imposes new limits on extra costs for copayments, deductibles and coinsurance that will benefit cancer patients. Also included are insurance companies which will cover standard-of-care costs for clinical trials enabling patients to participate in vital part of cancer research.

The author discusses the delivery of the original principles of Medicare in Australia. He mentions that health care becomes complex, responding to alterations in reimbursement structures and modern epidemic of chronic disease. He states that the proposed $7 mandatory copayment for radiology services and general practitioner visits disregards the fact that many patients are paying copayments for other services.

The author discusses the general practitioner copayment introduced by the Australian federal government into Medicare arrangements. The author mentions the report from health costs researcher Jennifer Doggett, who was commissioned by the Consumer Health Reform (CHF), which reveals that copayments result in decreased health care access.

The article informs that a new telehealth industry group "One In Four Lives" has recommended to adopt a national telehealth strategy to take full advantage of the potential of telehealth and introduce a co-payment capability in the telehealth MBS item schedule. It is noted that the group beluieves that it would significantly cut hospital admissions for chronic conditions and reduce public hospital costs by around 4 billion dollar a year.

The author discusses the impact of out-of-pocket (OOP) expenditure on the use of healthcare by patients with less financial means. She mentions the use of copayments in healthcare and the problem that consumers in health care industry are not always good in judging the most effective. She suggests the development of procedure to examine the social value of health care interventions.

The article discusses the study of Brown University and Harvard University on the advantage of copayments in helping women get preventive care. The study suggested that a copayment of as little as $12.50 may help women avail of screening mammogram. Furthermore, it is stated that women in cost-sharing plans have lower screening rates than those member of Medicare manage-care plans with mammography.