Accounting for the burden and redistribution of health care costs: Who uses care and who pays for it

Carman, Katherine Grace; Liu, Jodi L.; White, Chapin

doi:10.1111/1475-6773.13258

Cited by 18 publications

(15 citation statements)

References 14 publications

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“…1 The continued use of these services creates health and cost burdens for patients and society. 2 The COVID-19 pandemic interrupted some lowvalue services (along with high-value care), but paths to sustaining these lower rates remain unclear. 3 This is partly because low-value care has largely been measured and reported at the national or regional level, limiting accountability and actionability.…”

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confidence: 99%

Low-Value Care at the Actionable Level of Individual Health Systems

et al. 2021

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IMPORTANCE Low-value health care remains prevalent in the US despite decades of work to measure and reduce such care. Efforts have been only modestly effective in part because the measurement of low-value care has largely been restricted to the national or regional level, limiting actionability.OBJECTIVES To measure and report low-value care use across and within individual health systems and identify system characteristics associated with higher use using Medicare administrative data. DESIGN, SETTING, AND PARTICIPANTSThis retrospective cohort study of health system-attributed Medicare beneficiaries was conducted among 556 health systems in the Agency for Healthcare Research and Quality Compendium of US Health Systems and included system-attributed beneficiaries who were older than 65 years, continuously enrolled in Medicare Parts A and B for at least 12 months in 2016 or 2017, and eligible for specific low-value services. Statistical analysis was conducted from January 26 to July 15, 2021. MAIN OUTCOMES AND MEASURESUse of 41 individual low-value services and a composite measure of the 28 most common services among system-attributed beneficiaries, standardized to distance from the mean value. Measures were based on the Milliman MedInsight Health Waste Calculator and published claims-based definitions.RESULTS Across 556 health systems serving a total of 11 637 763 beneficiaries, the mean (SD) use of each of the 41 low-value services ranged from 0% (0.01%) to 28% (4%) of eligible beneficiaries. The most common low-value services were preoperative laboratory testing (mean [SD] rate, 28% [4%] of eligible beneficiaries), prostate-specific antigen testing in men older than 70 years (mean [SD] rate, 27% [8%]), and use of antipsychotic medications in patients with dementia (mean [SD] rate, 24% [8%]). In multivariable analysis, the health system characteristics associated with higher use of low-value care were smaller proportion of primary care physicians (adjusted composite score, 0.15 [95% CI, 0.04-0.26] for systems with less than the median percentage of primary care physicians vs −0.16 [95% CI, -0.27 to -0.05] for those with more than the median percentage of primary care physicians; P < .001), no major teaching hospital (adjusted composite, 0.10 [95% CI, -0.01 to 0.20] without a teaching hospital vs −0.18 [95% CI, -0.34 to -0.02] with a teaching hospital; P = .01), larger proportion of non-White patients (adjusted composite, 0.15 [95% CI, -0.02 to 0.32] for systems with >20% of non-White beneficiaries vs −0.06 [95% CI, -0.16 to 0.03] for systems with Յ20% of non-White beneficiaries; P = .04), headquartered in the South or West (adjusted composite, 0.28 [95% CI, 0.14-0.43] for the South and 0.22 [95% CI, 0.02-0.42] for the West compared with −0.09 [95% CI, -0.26 to 0.08] for the Northeast and −0.44 [95% CI, -0.60 to -0.28] for the Midwest; P < .001), and serving areas with more health care spending (adjusted composite, 0.23 [95% CI, 0.11-0.35] for areas above the median level of spending vs −0.24 [95% CI, -0.36 to -0....

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confidence: 99%

Low-Value Care at the Actionable Level of Individual Health Systems

et al. 2021

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“…Total health care payments, including premiums paid by workers and their employers, taxes paid, and out-of-pocket spending, consumed 33.9% of income for the poorest fifth of the population, but only 16% for the wealthiest fifth. 9 A new NPR/Robert Wood Johnson Foundation/ Harvard School of Public Health survey has found that even wealthy Americans sometimes have difficulty affording care. Among the wealthiest 1% of adults (those with household incomes above $500,000), 5% reported a serious problem paying medical bills within the past few years, 5% had a serious problem paying for prescription drugs, and 7% reported a serious problem getting health care when needed.…”

Section: Access To Care and Medical Costsmentioning

confidence: 99%

The U.S. Health Care System on the Eve of the Covid-19 Epidemic: A Summary of Recent Evidence on Its Impaired Performance

Himmelstein

Woolhandler

2020

Int J Health Serv

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Four decades of neoliberal health policies have left the United States with a health care system that prioritizes the profits of large corporate actors, denies needed care to tens of millions, is extraordinarily fragmented and inefficient, and was ill prepared to address the COVID-19 pandemic. The payment system has long rewarded hospitals for providing elective surgical procedures to well-insured patients while penalizing those providing the most essential and urgent services, causing hospital revenues to plummet as elective procedures were cancelled during the pandemic. Before the recession caused by the pandemic, tens of millions of Americans were unable to afford care, compromising their physical and financial health; deep-pocketed corporate interests were increasingly dominating the hospital industry and taking over physicians’ practices; and insurers’ profits hit record levels. Meanwhile, yawning class-based and racial inequities in care and health outcomes remain and have even widened. Recent data highlight the failure of policy strategies based on market models and the need to shift to a nonprofit social insurance model.

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“…Survey data has also been used to examine the distributional effects of health care cost sharing and health insurance schemes, e.g. by microsimulation and other quantitative methods [33][34][35][36][37]. In a Canadian study, household expenditure survey data and quasi-experimental design were used to examine the distributional effects of introduced prescription medicine subsidy programs [38].…”

Section: Introductionmentioning

confidence: 99%

The effect of pharmaceutical co-payment increase on the use of social assistance—A natural experiment study

Rättö

Aaltonen

2021

PLoS ONE

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Health care out-of-pocket payments can create barriers to access or lead to financial distress. Out-of-pocket expenditure is often driven by outpatient pharmaceuticals. In this nationwide register study, we study the causal relationship between an increase in patients’ pharmaceutical expenses and financial difficulties by exploiting a natural experiment design arising from a 2017 reform, which introduced higher co-payments for type 2 diabetes medicines in Finland. With difference-in-differences estimation, we analyze whether the reform increased the use of social assistance, a last-resort financial aid. We found that after the reform the share of social assistance recipients increased more among type 2 diabetes patients than among a patient group not affected by the co-payment increase, suggesting the reform increased the use of social assistance among those subject to it. The results indicate that increases in patients’ pharmaceutical expenses can lead to serious financial difficulties even in countries with a comprehensive social security system.

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Accounting for the burden and redistribution of health care costs: Who uses care and who pays for it

Cited by 18 publications

References 14 publications

Low-Value Care at the Actionable Level of Individual Health Systems

Low-Value Care at the Actionable Level of Individual Health Systems

The U.S. Health Care System on the Eve of the Covid-19 Epidemic: A Summary of Recent Evidence on Its Impaired Performance

The effect of pharmaceutical co-payment increase on the use of social assistance—A natural experiment study

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