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The article offers information on minimum clinically important difference (MCID) to better evaluate the clinical relevance of changes in scores of quality-of-life instruments. Topics discussed include focus on patient-reported outcome measures (PROMs) evaluation and value-based health care; using predetermined algorithms by evaluating absolute and relative changes in patient self-reported pain, function, and global assessment; and determining the bare minimum change in PROMs.

The article discusses the results of the Affordability and Real-World Antiplatelet Treatment Effectiveness After Myocardial Infarction Study (ARTEMIS), that was published within the issue. Topics covered include the ability of co-payment vouchers for PSY12 inhibitors to reduce major adverse cardiovascular events (MACE), adherence to dual antiplatelet therapy, and the increased use of ticagrelor.

The article discusses deregulation of medical fees and co-payments. Topics discussed include the affirmation of the Australian Medical Association (AMA) that Medicare Benefits Schedule (MBS) rebates have not been indexed to keep pace with the consumer price index (CPI), the benefits which can be gained by private insurers which doctors decline to charge the insurer's fee in a "no gap" plan, and significance of reviewing the fee-for-service delivery paradigm.

Although co-payments and deductibles are means of keeping health expenditures low, they have also been cited as barriers that inhibit patients from accessing necessary healthcare. We aimed to evaluate Rhode Island residents' experiences with cost-related access challenges within the state's healthcare system. We conducted a cross-sectional survey of resident experiences with healthcare in Rhode Island. Our survey instrument was composed of the RAND Corporation "Short-Form Patient Satisfaction Questionnaire (PSQ-18)", questions developed by the Rhode Island Office of the Health Insurance Commissioner, and ranking of health priorities based on prior community assessments conducted by the Rhode Island Department of Health. Data were collected at venues across the state as part of the Rhode Island Department of Health 2015 Statewide Health Inventory. From July to August 2015, 404 surveys were completed. We found that 40% of respondents had a co-pay of $20-$50, while 35.7% of respondents had a deductible of greater than $500. Further, one-third of respondents delayed receiving care due to financial barriers. This decision resulted in a worsening condition or hospital visit for nearly half of those respondents. Co-pays and deductibles pose challenges to Rhode Islanders accessing health care. Cost-related barriers to healthcare access should continue to be addressed, especially in the context of preventive care services, which are now being built into health insurance premiums through the Patient Protection and Affordable Care Act. [ABSTRACT FROM AUTHOR]

Investigating the factors that drive differences in preferences for health insurance products among rural populations is a relevant policy issue that has so far received little attention. This study used a discrete choice experiment to explore heterogeneity of preferences for a prospective micro-health insurance (MHI) product in Malawi. Through an extensive qualitative study, six attributes, each associated with three levels, were derived and used to construct a D-efficient design. The attributes included unit of enrollment, management structure, health service benefit package, copayment levels, transportation coverage and monthly premium. The experiment was interviewer administered to a stratified random sample of household heads and their spouse(s). Using mixed logit and generalized multinomial logit models, respondent characteristics were interacted with MHI attributes to explore heterogeneity of preferences. The results showed that those in the higher age group (≥55 years) and those from households with higher household expenditure had significantly higher preferences for comprehensive and medium benefit packages than for a basic package. Those from households that incurred any healthcare expenditure within the past 4 weeks had lower preferences for the core family as a unit of enrollment than the individual, and higher preferences for coverage of transport costs. Women and non-micro-finance members had higher preferences for 25% copayment than for 50% copayment. There was evidence of scale heterogeneity signifying that the observed preference variations could have resulted from scale and variance differences, rather than real variations in the taste of respondents. To attract the relatively older and wealthier, prospective MHI should offer comprehensive health services benefit packages. Premium exemptions or subsidies should also be offered to the poor. Lower copayments can provide an incentive for women and non-micro-finance members, whilst coverage of transport costs can also attract those with recent history of incurring out-of-pocket healthcare expenditure to accept MHI. [ABSTRACT FROM AUTHOR]

Objectives: This paper aims at covering a literature gap on the effects of copayments, prescription quotas and therapeutic reference pricing on public and private expenditures and volumes (1) When these policies are implemented in different areas at different times, (2) estimating their impact in the short and long run, (3) assessing the extent to which these impacts are interdependent, (4) scrutinising the extent to which the effects are mediated by prescribers' and patients' behaviours.Methods: Monthly regional data on pharmaceutical expenditures, volumes and policies in Italy from 2000 to 2014 are analysed using a difference-in-differences model enriched to capture short- versus long-term effects and simultaneous and interactive effects. Sobel-Goodman test and bootstrap analyses were used to test for mediation.Results: The three policies have different short- and long-run effects. Interactions support the hypothesis of reinforcing effects. Behavioural reactions to policies such as reducing the demand or total per capita expenditures mediate the impact of policies, thus explaining the different effects between the short and long term.Conclusions: Evidence on the impact over time of regional policies diversely introduced in different times have important policy implications. First, pharmaceutical policies interact with each other, and the combined effect may be different from what we would expect from the sum of each single policy. Hence, policymakers should be very careful in designing mixed policies for their unexpected combined effects. Second, the impact of policies tends to reduce over time. If longer-term impact is desired, it would be appropriate to introduce some adjustments over time. Third, policies have multiple effects, and this should be considered when they are designed. Finally, pharmaceutical policies may have an unintended impact on health and health care. [ABSTRACT FROM AUTHOR]

Background: Although bodies of evidence on copayment effects on access to care and quality of care in general have not been conclusive, allowing copayment in the case of emergency medical conditions might pose a high risk of delayed treatment leading to avoidable disability or death. Methods: Using mixed-methods approach to draw evidence from multiple sources (over 40,000 records of administrative dataset of Thai emergency medical services, in-depth interviews, telephone survey of users and documentary review), we are were able to shed light on the existence of copayment and its related factors in the Thai healthcare system despite the presence of universal health coverage since 2001. Results: The copayment poses a barrier of access to emergency care delivered by private hospitals despite the policy proclaiming free access and payment. The copayment differentially affects beneficiaries of the major 3 public-health insurance schemes hence inducing inequity of access. Conclusions: We have identified 6 drivers of the copayment i.e., 1) perceived under payment, 2) unclear operational definitions of emergency conditions or 3) lack of criteria to justify inter-hospital transfer after the first 72 h of admission, 4) limited understanding by the service users of the policy-directed benefits, 5) weak regulatory mechanism as indicated by lack of information systems to trace private provider's practices, and 6) ineffective arrangements for inter-hospital transfer. With demand-side perspectives, we addressed the reasons for bypassing gatekeepers or assigned local hospitals. These are the perception of inferior quality of care and age-related tendency to use emergency department, which indicate a deficit in the current healthcare systems under universal health coverage. Finally, we have discussed strategies to address these potential drivers of copayment and needs for further studies. [ABSTRACT FROM AUTHOR]

This article analyses how health-care utilization is affected by copayments in a tax-financed health-care system. The article utilizes a natural experiment in which a health-care region in Sweden changed the price of healthcare in such a way that primary care general physician prices increased by 33%. We use daily visit data in the treatment region and a neighbouring control region where no price change took place and analyse the effect using differences-in-differences as well as differences-in-differences-in-differences models. The results from the preferred models indicate no effect on health-care utilization due to the price change, a result that also holds across different socio-economic subregions in the treatment region. [ABSTRACT FROM AUTHOR]

This paper estimates the effect of the abolition of user charges for children's outpatient care (30 CZK/1.2 EUR) in 2009 on the demand for ambulatory doctor visits in the Czech Republic. Because the reform applied only to children, we can employ the difference-in-differences approach, where children constitute a treatment group and adults serve as a control group. The dataset covers 1841 observations. Aside from the treatment effect, we control for a number of personal characteristics using micro-level data (European Union Statistics on Income and Living Conditions). Using the zero-inflated negative binomial model, we found no significant effect from the abolition of user charges on doctor visits, suggesting either that user charges are ineffective in the Czech environment or that their value was set too low. On the contrary, personal income, the number of household members and gender have a significant effect. A number of robustness checks using restricted samples confirm the results. [ABSTRACT FROM AUTHOR]

A decade of rapidly rising outpatient advanced imaging utilization ended toward the end of the past decade, with slow growth since. This has been attributed to repetitive reimbursement cuts, medical radiation exposure concerns, increasing deductibles and patient copayments, and the influence of radiology benefit management companies. State Medicaid programs have been reluctant to institute radiology benefit management preauthorization programs since the time burden for obtaining test approval could cause providers to drop out. Also, these patients may lack the knowledge to appeal denials, and medically necessary tests could be denied with adverse outcomes. Little data exist demonstrating the efficacy of such programs in decreasing utilization and cost. We report a 2-year experience with an outpatient advanced imaging prior notification program for a large state Medicaid fee-for-service population. The program did not allow any denials, but nevertheless the data reveal a large, durable decrease in advanced imaging utilization and cost. [ABSTRACT FROM AUTHOR]

In Portugal, Civil Servants may have a differential utilization of health services due to their supplementary Health Subsystem (ADSE), which grants them access to health services in the private sector at lower price. We exploit the impact of this double coverage on the demand for Portuguese Public Emergency Departments (ED), following the recent increase in co-payments for public health care services in Portugal. Using detailed ED level data from three different EDs, one for each level of the Portuguese ED care, we rely on a difference-in-differences strategy, under the assumption that both civil servants and National Health Service (NHS) users were targeted by the public co-payment increase, but just the former have a low-cost alternative in the private sector that they can use when prices increase in the NHS. We found that the existence of a low-price alternative in the private sector caused ED demand to decrease among ADSE beneficiaries following a policy that increased co-payments in public NHS hospitals. Specifically, we show that this decrease was only significant for conditions which have arguably the closest substitutes in the private sector - the low and intermediate-severity conditions - and to patients who lived closer to the ED and to whom the co-payment was the largest share of the ED visit cost. These findings cast some concerns over the equity of the Portuguese Health System, since civil servants increasingly opt out from public health services but must co-fund both the ADSE and the NHS. [ABSTRACT FROM AUTHOR]

Background: Co-payment for methadone maintenance treatment (MMT) services is a strategy to ensure the financial sustainability of the HIV/AIDS programs in Vietnam. In this study, we examined health services utilization and expenditure among MMT patients, and further explored factors associated with catastrophic health expenditure among affected households.Methods: A multi-site cross-sectional study was conducted among 1016 patients in two epicentres: Hanoi and Nam Dinh province in 2013.Results: Overall, 8.2% and 28.7% respondents used inpatient and outpatient health care services in the past 12 months apart from receiving MMT. There were 12.8% respondents experiencing catastrophic health expenditure given MMT is provided free-of-charge, otherwise 63.5% patients would suffer from health care costs. MMT integrated with general health or HIV services may encourage health care services utilization of patients. Patients, who were single, lived in the rural, had inpatient care and reported problems in Mobility were more likely to experience catastrophic health expenditure than other patient groups.Conclusions: The health care costs are still financially burden to many drug users and remained over the course of MMT that implies the necessity of continuous supports from the program. Scaling-up and decentralizing integrated MMT clinics together with economic empowerments for treated drug users and their families should be prioritized in Vietnam. [ABSTRACT FROM AUTHOR]

In current Chinese health insurance programmes, there are two types of cost-sharing methods: the time-of-service copayment policy and the reimbursement policy. In contrast to the copayment participants, reimbursement participants need to pay for all medical expenses in advance. We study the effect of the reimbursement policy on the utilisation of healthcare services in China. The theoretical analysis indicates that the medical consumption of low income households will be less than the optimal consumption level when enrolled in a reimbursement programme instead of a copayment programme. Empirically, using data from the China Health and Retirement Longitudinal Study (CHARLS), we find that the total inpatient expenditure of the reimbursement participants is 12.7% lower than that of copayment enrolees, and the reimbursement arrangement negatively impacts low-income and rural populations. Therefore, reimbursement participants, those who are financially constrained, are more likely to suffer the up-front payment burden and finally reduce their healthcare needs. [ABSTRACT FROM PUBLISHER]

Context: The onset of COVID-19 has required the rapid adoption of virtual services in primary care (PC) practices, and virtual care delivery is likely to continue to some extent post-pandemic. Objective: To understand patient experience with synchronous virtual (telephone (Tel)/Video) appointments and elicit recommendations for its future use. Design: Mixed method, including patient survey co-developed with stakeholders and implemented online Feb-Mar 2021 with large promotional efforts through social media, patient and caregiver organizations, and other networks. We report on the survey results. Eligibility: 1+ virtual encounter in PC. Outcome measures: A) Patient experience scale (12/17 questions for Tel/Video) covering 4 sub-dimensions; B) Access related questions. Questions had 5-point Likert scale items (strongly disagree (-2) to strongly agree (+2)) and were converted into percentage (potential range -100%, +100%) Setting : Ontario, Canada which offers universal coverage for PC visits with no co-payment. Results: 534 eligible respondents (402/18/114 had Tel/Video/both): Females (78%), < 55 years (61%), white (75%), employed (61%), bachelor's degree (74%), family income > 100k (52%). Encounters evaluated were with family physicians (vs other health professionals) for 75%/46% of Tel/Video encounters. A) Patient Experience (Tel/Video) overall score: 75%/78%; Sub-dimensions: technology: 92%/84%, patient-provider relationship: 83%/86%, quality of care: 66%/66%, whole-person care: 43%/53%. Factors associated with a statistically significant(*) > 10% higher overall score in tel and/or video were: non-females: (8%*/14%*), French speaking (13%*/16%*), patient-provider relationship >1 year (16%*/7%), provider age < 50 (5%/15%*), having the choice of appointment time (15%*/21%*). Wanting to show problem to the provider was associated with a lower scores (-23%*/NA). B) Access Respondents overwhelmingly reported that Tel/Video visits reduced time (97%/97%), costs (81%/85%), and was more convenient (91%/91%). The majority wanted Tel (69%) and Video (71%) visits at least as often as in person visits post-covid. Only 5% did not want any future virtual care. Conclusions: Patient experience was largely positive and is influenced by patient/provider factors. Patients and providers may benefit from support/training to optimize care experience. We are now evaluating whether the reasons for visits influences care experience. [ABSTRACT FROM AUTHOR]

Context: COVID-19 led to a rapid uptake of virtual care appointments (telephone and video) in primary care (PC). Decisions on the future of virtual care need to consider patients' experiences. Objective: To understand patients' experience with virtual care appointments. Study Design: Mixed methods study, presentation focus on qualitative data. A semi-structured interview guide was co-created with patient advisors. A broad recruitment strategy included emailing patient and community organizations, research team network, and social media. Data analyzed using thematic analysis. Participant Eligibility: At least one synchronous virtual encounter in PC since March 2020. Setting: Ontario (Canada) offers universal coverage for PC visits with no co-payment. Results: N=55 interviews were conducted between January 2021 and March 2021. Technology: Telephone was preferred modality. Access: Virtual care was convenient and saved patients' time and money. Appointment scheduling & booking processes were barriers. Privacy and Confidentiality: No concerns about privacy & confidentiality in patients' environment, yet participants wanted assurance about privacy & confidentiality in providers' environment. Communication: Providers' detailed explanations, patients' health literacy levels, and asynchronous methods of sharing information and documents before and/or after appointments facilitated good experiences. Lack of body-language was a barrier. Therapeutic Relationship: Strong preexisting relationships facilitated good virtual care experiences. Participants expressed concerns about long-term erosion of relationship when using virtual care. Whole-Person Care: Virtual care facilitated easy inclusion of family members in appointments. However, virtual care appointments were more problem-focused and included less conversation topics outside of specific problem than in-person appointments. Quality of Care: Most participants reported quality of virtual care was similar to in-person appointments; although, a few participants reported it was worse. Conclusions: Virtual care was effective for appointment reasons that did not require physical exam or visual assessment, with mixed opinions about mental health care. Patient experiences were largely positive and the adoption of virtual care must consider potential longer-term impact on the therapeutic relationship and whole-person care, and will require training/guidelines to optimize care and patient experience. [ABSTRACT FROM AUTHOR]

This paper estimates the trade-off between salary and health insurance costs using data on Illinois school teachers between 1991 and 2008 that allow us to address several common empirical challenges in this literature. Teachers paid about 17 percent of the cost of individual health insurance and about 46 percent of the cost of their family members' plans through premium contributions, but we find no evidence that teachers' salaries respond to changes in insurance costs. Consistent with a higher willingness to pay for insurance, we find that premium contributions are higher in districts that employ a higher-tenured workforce. We find no evidence that school districts respond to higher health insurance costs by reducing the number of teachers. [ABSTRACT FROM AUTHOR]

Informal payments constitute a significant portion of out-of-pocket payments in health systems, especially in developing countries. This study examined the current status of informal payments in Turkey and the opinions, attitudes, and behavior of individuals toward informal payments. To examine this concept, 1,033 residents in Ankara, the capital city of Turkey, were surveyed. The 28-item questionnaire used in data collection was developed based on previous research and expert opinions. The data analysis revealed that approximately 29% of the study participants made informal payments in return for the medical service they received. Three out of 4 people who made informal payments were from a low-income group. Informal payments were made in the form of cash prior to medical procedures and also as gifts following the procedures. Future recommendations for health policymakers include designing a new patient copay mechanism where informal payments can be effectively incorporated into the formal payment system, assistance to low-income individuals, and improvement in current medical staff salaries that would discourage taking such payments. [ABSTRACT FROM PUBLISHER]

School-based, free HPV vaccination for girls in the first year of secondary school was introduced in Flanders (Belgium) in 2010. Before that, non school-based, co-payment vaccination for girls aged 12–18 was in place. We compared vaccination coverage, age-specific coverage and socio-economic inequalities in coverage – 3 important parameters contributing to the effectiveness of the vaccination programs – under both vaccination systems. We used retrospective administrative data from different sources. Our sample consisted of all female members of the National Alliance of Christian Mutualities born in 1995, 1996, 1998 or 1999 ( N = 66,664). For each vaccination system we described the cumulative proportion HPV vaccination initiation and completion over time. We used life table analysis to calculate age-specific rates of HPV vaccination initiation and completion. Analyses were done separately for higher income and low income groups. Under non school-based, co-payment vaccination the proportions HPV vaccination initiation and completion slowly rose over time. By age 17, the proportion HPV vaccination initiation/completion was 0.75 (95% CI 0.74–076)/0.66 (95% CI 0.65–0.67). The median age at vaccination initiation/completion was 14.4 years (95% CI 14.4–14.5)/15.4 years (95% CI 15.3–15.4). Socio-economic inequalities in coverage widened over time and with age. Under school-based, free vaccination rates of HPV vaccination initiation were substantially higher. By age 14,the proportion HPV vaccination initiation/completion was 0.90 (95% CI 0.90–0.90)/0.87 (95% CI 0.87–0.88). The median age at vaccination initiation/completion was 12.7 years (95% CI 12.7–12.7)/13.3 years (95% CI 13.3–13.3). Socio-economic inequalities in coverage and in age-specific coverage were substantially smaller. [ABSTRACT FROM AUTHOR]

The authors discuss applicable polices for reducing use of the emergency department (ED) among new Medicaid enrollees as to the Affordable Care Act (ACA) law. The authors agree with study findings that imposing copayments in nonemergency visits of Medicaid beneficiaries do not reduce ED visits. Also discussed are other ED alternatives such as charging higher rates for ED visits, access to primary care providers, medical home care model that is patient-centered and community health centers.

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.

This Viewpoint describes the drivers of more physician practices turning into bill collectors, the consequences for those clinicians, a wave of new companies looking to solve the problem, and what might be done to improve the situation. [ABSTRACT FROM AUTHOR]

This paper studies a market for a medical product in which there is perfect competition among health insurers, while the good is sold by a monopolist. Individuals differ in their severity of illness and there is ex postmoral hazard. We consider two regimes: one in which insurers use coinsurance rates (ad valorem reimbursements) and one in which insurers use co-payments (specific reimbursements). We show that the induced equilibrium with co-payments involves a lower producer price and a higher level of welfare for consumers even though it may imply a larger consumer price. This result provides strong support for a reference price based reimbursement policy. [ABSTRACT FROM AUTHOR]