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PubMed2002

Institutionalising cost sharing for catchment management: lessons from land and water management planning in Australia.

A recurring theme in recent Australian reports on integrated catchment management (ICM) has been the need to institutionalise more formally the cost-sharing commitments made within this domain. This represents a significant departure from earlier visions of ICM as essentially promoting voluntary uptake of resource-conservation measures. Two important questions raised by this nascent policy shift are addressed in this paper. Firstly, how might cost-sharing arrangements be given greater formality without undermining the efforts of ICM to increase the preparedness of civil stakeholders to voluntarily, or informally, accept responsibility for sharing costs? Secondly, how is it possible to formalise cost-sharing arrangements so that the transaction costs of enforcing compliance with them remain affordable? Answers to these questions are explored through a case study of the Land and Water Management Planning Program now being successfully implemented in the irrigation districts of the central-Murray region of southern inland New South Wales (NSW) surrounding Deniliquin. The sophisticated system of institutional arrangements introduced in the program to facilitate monitoring, enforcement and adaptive management of cost-sharing commitments is discussed, and insights into how informally motivated cooperation can enhance the affordability and political feasibility of formal arrangements are presented.

Australia↗
PubMed2004

Discontinuation of cost sharing in Uganda.

OBJECTIVE: To assess the effects of ending cost sharing on use of outpatient services and how this was perceived by health workers and members of a health unit management committee. METHODS: From 10 districts across Uganda, 78 health facilities were selected. Attendance at these facilities was assessed for eight months before and 12 months after cost sharing ended. The data represented 1 966 522 outpatient visits. Perceptions about the impact of ending cost sharing were obtained from the 73 health workers and 78 members of the health unit management committee who were available. FINDINGS: With the end of cost sharing, the mean monthly number of new visits increased by 17 928 (53.3%), but among children aged <5 years the increase was 3611 (27.3%). Mean monthly reattendances increased by 2838 (81.3%) among children aged <5 years and 1889 (24.3%) among all people. Attendances for immunizations, antenatal clinics, and family planning all increased, despite these services having always been free. Health workers reported a decline in morale, and many health unit management committees no longer met regularly. CONCLUSION: Use of all services increased - even those that had never before been subject to fees. The loss of some autonomy by the health facility and diminished community governance of health facilities may have long term negative effects.

Attitude of Health Personnel↗
PubMed1988

Assessment of the effects of cost-sharing in Yugoslavia.

In this study the existing forms and amounts of cost-sharing in the Republic of Serbia (Yugoslavia) are analyzed. The level of cost-sharing is ranked according to the number and type of services involved and the relative importance with which they are viewed within the overall health-care policy of Yugoslavia. The "self-managing community of interest of health care," administratively coincident with the district, is taken as the unit of observation. Until recently, these bodies independently decided whether to introduce cost-sharing as well as the rate of cost-sharing. Therefore, the implementation of this health-policy measure differed among the districts generating inequality within health-care system. The results of simple and multiple correlation indicate that poorer districts with fewer health resources and lower levels of consumption introduced cost-sharing for more services, attempting to provide additional resources for financing of the health-care system. The multiple linear-regression model shows that population/physician ratio and the use of primary care physicians' services are the significant indicators of health-care expenditures in this territory. Considering the current economic situation in Yugoslavia and the level of development of the health-care system, the results of this cross-sectional study imply that cost-containment in health care can be achieved in a more equitable and effective manner by controlling supply of health services than by limiting demands.

Cost Allocation↗
PubMed2002

Preferences for patient cost sharing among medicare beneficiaries after HMO plan withdrawals.

OBJECTIVE: To assess Medicare beneficiaries' willingness to cost share in order to minimize disruptions in coverage from HMO plan withdrawals. DESIGN: Cross-sectional survey of Medicare beneficiaries from February 1999 to March 1999. SETTING: Ten U.S. counties with the highest HMO plan withdrawal rates. PATIENTS/PARTICIPANTS: Seven hundred one Medicare beneficiaries for response rate of 69%. MEASUREMENTS AND MAIN RESULTS: Percentage of respondents willing to accept more out-of-pocket costs in order to continue their Medicare HMO coverage. Most respondents (67%) were willing to pay more out-of-pocket costs so that their HMO could have continued Medicare coverage. Those who were white (P =.03), had higher incomes (P =.01), and returned to traditional fee-for-service Medicare (P =.004) were more likely than other respondents to accept increased patient cost sharing. Most beneficiaries preferred Medicare policies requiring HMOs to sign longer-term Health Care Financing Administration (HCFA) contracts (72%) and to offer coverage to beneficiaries regardless of where they lived in a given state (87%). However, respondents' preferences for such policy options were not associated with the amount of cost sharing that respondents were willing to accept. CONCLUSIONS: Most Medicare beneficiaries are willing to accept increased patient cost sharing in order to reduce disruptions in their HMO coverage. Policies intended to reduce HMO plan withdrawals, such as requiring health plans to sign longer-term HCFA contracts, are supported by many Medicare beneficiaries, but these policy preferences were not related to willingness to cost share. In light of an apparent willingness to pay more out-of-pocket medical costs, Medicare beneficiaries in general may accept increased cost sharing in order to retain their HMO coverage.

Age Factors↗
PubMed1991

A comparison of cost-sharing versus free care in children: effects on the demand for office-based medical care.

Using data from the community based RAND Health Insurance Experiment, the effect of cost-sharing versus free care on the use of office-based medical care in children was examined. Children from families on cost-sharing plans had a 22 percent lower probability (P less than 0.005) of having an episode of care during the study year. Both the number of episodes of care and total charges for outpatient professional services were 30 percent lower (P less than 0.005) with cost-sharing. cost-sharing reduced average charges for medical services by 30 percent (P less than 0.01) and pathology charges by 45 percent (P less than 0.005). cost-sharing reduced medical services received by 26 percent (P less than 0.05) and pathology services received by 43 percent (P less than 0.05) but did not have a significant effect on either the price for medical services or pathology services. It was concluded that there is a large difference between cost-sharing insurance plans and free care in the demand for office-based medical care in children. Cost-sharing results in children receiving fewer services, not lower priced services.

Child↗
PubMed2005

Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much?

BACKGROUND: For patients with a chronic disease, increased cost-sharing for medications may lead to unintended consequences, including reduced use of medications essential for control of their disease. OBJECTIVE: The objective of this study was to estimate the effects of small ($1-6 per 30-day supply), moderate ($7-10), and large (>$10) increases in medication cost-sharing on 12-month trends in oral hypoglycemic (OH) use among adults with type 2 diabetes. METHODS: We conducted a quasiexperimental study using a time series with comparison group design. Data were obtained from computerized membership, benefit, and pharmacy dispensing data of 5 managed care organizations (MCOs). A total of 13,110 12-month episodes of OH use and a medication cost-sharing increase ("intervention") were matched with 13,110 that had no increase. The dependent variable was OH average daily dose (ADD) standardized to each episode's mean OH ADD in the 6-month preintervention period. The principal independent variable was change in cost per 30-day OH supply between the 6-month pre- and postintervention periods. Effects of changes in cost-sharing on OH ADD were estimated using segmented time series regression. RESULTS: Episodes with >$10 increase in cost-sharing had significantly (alpha=0.05) decreased OH ADD in the postintervention period. At 6 months after this increase, OH ADD had decreased by 18.5% from that predicted from the preintervention trend. Episodes with a $1 to $10 increase in cost-sharing and those with no increase in cost-sharing had significant linear increases in OH use over the 12-month period. CONCLUSIONS: Large increases in medication cost-sharing were associated with immediate and persistent reductions in OH use. Small and moderate increases had little effect on OH use in the 6-month period after the increase.

Adolescent↗
PubMed2000

The direct and indirect effects of cost-sharing on the use of preventive services.

OBJECTIVE: To test empirically a model for estimating the direct and indirect effects of different forms of cost-sharing on the utilization of recommended clinical preventive services. DATA SOURCES/SETTINGS: Stratified random sample of 10,872 employees, 18-64 years, who had belonged to their plan for at least one year, from seven large companies that were members of the Pacific Business Group on Health (PBGH) in 1994. DATA COLLECTION: The 1994 PBGH Health Plan Value Check Survey. 1994 PBGH data on requirements for employee out-of-pocket patient cost-sharing for 52 different health plans. DESIGN: Five equations were derived to estimate the direct and indirect effects of two forms of cost-sharing (copayments and coinsurance/deductibles) in two forms of managed care (HMOs and PPO/indemnity plans) on four clinical preventive services: mammography screening, cervical cancer screening, blood pressure screening, and preventive counseling. Probit models were used to estimate elasticities for the indirect and direct effects. PRINCIPAL FINDINGS: Both forms of cost-sharing in both plan types had negative and significant indirect effects on preventive counseling (from -1 percent to -7 percent). The direct effect of cost-sharing was negative for preventive counseling (-5 percent to -9 percent) and Pap smears (from -3 percent to -9 percent) in both HMOs and PPOs, and for mammography only in PPOs (-3 percent to -9 percent). The results of the effects on blood pressure screening are inconclusive. CONCLUSIONS: Both the direct and indirect effects of cost-sharing negatively affected the receipt of preventive counseling in HMOs and PPOs. As predicted, the direct negative effect of cost-sharing was greater than the indirect effect for Pap smears and mammography. Eliminating cost-sharing for these services may be important to increasing their utilization to recommended levels.

Adolescent↗
PubMed2004

Patient cost-sharing innovations: promises and pitfalls.

Over the next decade, health plans and employers will refine patient cost sharing to encourage workers to seek more cost-effective care, according to a panel of market and health policy experts at a Center for Studying Health System Change (HSC) conference. Instead of using a single, large deductible, employers and health plans will likely vary patient cost sharing by choice of provider, site and type of service, so patients choosing less effective care options pay more. Employers also will try to limit financial hardships for low-income workers by, for example, varying cost sharing based on workers' income. However, significant obstacles could hinder the effectiveness of emerging cost-sharing strategies, including inadequate information on quality of care and provider resistance.

Community Participation↗
PubMed2005

The association of consumer cost-sharing and direct-to-consumer advertising with prescription drug use.

BACKGROUND: Previous research on the impact of various cost-sharing strategies on prescription drug use has not considered the impact of direct-to-consumer (DTC) advertising. OBJECTIVE: To explore the association of cost-containment strategies with prescription drug use and to determine if the association is moderated by DTC prescription drug advertising. METHODS: The study population included 288 280 employees and dependents aged 18 to 65 years with employer-sponsored health insurance contributing to the MEDSTAT MarketScan administrative data set. Person-level enrollment and claims data were obtained for beneficiaries enrolled continuously during July 1997 through December 1998. Direct-to-consumer advertising data were obtained from Competitive Media Reporting and linked to the MEDSTAT enrollment files. Localized DTC advertising expenditures for one class of medication were evaluated and matched with prescription claims for eligible MEDSTAT contributors. The association of various types and levels of cost-sharing incentives with incident product use was evaluated, controlling for the level of DTC advertising, health status, and other demographic covariates. RESULTS: The relationship of cost-sharing amounts with drug use was modified by the level of DTC advertising in a geographic market. This relationship was dependent on the type of cost-sharing, distinguishing between co-payments for provider visits and co-payments for prescription drugs. Compared with low-advertising markets, individuals residing in markets with high levels of advertising and paying provider co-payments of $10.00 or more were more likely to use the advertised product. In the same markets, higher prescription drug co-payments were associated with a decreased likelihood of using the advertised product. A similar relationship was not observed for the nonadvertised competitor. CONCLUSIONS: Among insured individuals, response to cost-sharing strategies is moderated by DTC prescription drug advertising. The relative ability of cost-sharing strategies to influence drug use should be interpreted with caution in the presence of DTC advertising.

2-Pyridinylmethylsulfinylbenzimidazoles↗
PubMed1985

The impact of cost sharing on emergency department use.

We studied the effect of insurance coverage on the use of emergency department services, using data from a national trial of cost sharing in health insurance. A total of 3973 persons below the age of 62 years were randomly assigned to fee-for-service health insurance plans with coinsurance rates of 0, 25, 50, or 95 per cent, subject to an income-related upper limit on out-of-pocket expenses. Persons with no cost sharing had emergency department expenses that were 42 per cent higher than those for persons on the 95 per cent plan (P less than 0.01) and about 16 per cent higher than those for persons with smaller amounts of cost sharing. Without cost sharing, emergency department visits for less serious diagnoses (e.g., abrasions) increased three times as much as did visits for more serious diagnoses (e.g., lacerations). After control for insurance, persons in the lower third of the income distribution had emergency department expenses that were 64 per cent higher than those in the upper third (P less than 0.001) and received a greater proportion of their ambulatory care in the emergency department. We conclude that the absence of cost sharing results in significantly greater emergency department use than does insurance with cost sharing. A disproportionate amount of the increased use involves less serious conditions.

Ambulatory Care↗
PubMed1982

Medicaid program; cost sharing demonstrations--HCFA. General notice.

HCFA is soliciting applications from State Medicaid agencies for demonstration projects that will permit States to apply cost sharing to any services for Medicaid eligible individuals. Currently, States are permitted to apply nominal cost sharing to any services for the medically needy, but only to optional services for the categorically needy. Research on cost sharing for the general population indicates it can have an effect on utilization of medical services. By allowing the States greater flexibility to apply a variety of approaches to cost sharing under Medicaid, we expect that States will conduct demonstrations to provide additional, useful information to HCFA, and through HCFA, to all the States, on the effectiveness of several methods of cost sharing. This information should enable HCFA to determine whether alternative methods of cost sharing will further the objectives of the Medicaid program by enabling States to continue to provide medical services. This solicitation also contains information about demonstration requirements and application procedures.

Centers for Medicare and Medicaid Services, U.S.↗
PubMed1993

Income-related cost sharing in health insurance.

The vast majority of health plans in the United States require patients to meet cost-sharing requirements that are unrelated to income. Because this is highly inequitable, the authors propose a new system in which cost sharing is explicitly linked to income levels. This proposal differs from earlier proposals to relate cost sharing to income, which relied on the federal income tax system. In this plan, employers and insurers (both public and private) would collect the information necessary to relate cost sharing amounts to income. The proposal could be applied to nearly any health system reform proposal currently under discussion. The authors examine the experience of a number of U.S. firms that have already incorporated income-related cost sharing, as possible models to apply to health insurance nationwide.

Cost Sharing↗
PubMed1989

Combining demand- and supply-side cost sharing: the case of inpatient mental health care.

Public and private payers can set the terms of demand-side cost sharing in insurance for patients and supply-side cost sharing in the form of reimbursement for providers. This paper summarizes a model in which health care utilization is affected by both demand- and supply-side cost sharing. The combined effects of these two policies are simulated in an application to inpatient mental health care. Because supply-side cost sharing (as would take place in a prospective payment system) limits cost without imposing financial risk on patients, it is preferred as a policy for restraining cost. I show in the case studied that when supply-side cost sharing is introduced, insurance coverage should improve.

Deductibles and Coinsurance↗
PubMed2004

Cost-sharing: patient knowledge and effects on seeking emergency department care.

BACKGROUND: The use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients' knowledge of cost-sharing or its influence on behavior. OBJECTIVE: The objective of this study was to evaluate what patients know about their individual levels of cost-sharing and how it influences decisions to seek care. STUDY DESIGN: We conducted a cross-sectional telephone survey with a 69% response rate. SUBJECTS: We studied a stratified random sample of 695 adult patients in an integrated delivery system: 266 subjects > or =65 years, 218 low-income subjects, and 211 subjects from the overall membership. MEASURES: We used perceived and actual levels of copayments for emergency department (ED) visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes. RESULTS: One third of subjects correctly reported their ED copayment, whereas three fourths correctly reported their prescription drug and office visit copayments. Over half of the subjects (57%) underestimated their ED copayment by $20 or more. Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, ie, delayed or avoided emergency care. The perceived copayment level was strongly associated with behavior change (odds ratio, 3.9). Other significant factors included having more ED visits in the past 12 months and having a low health status. CONCLUSIONS: Patients have less knowledge of their ED cost-sharing levels than for other services. The perceived copayment amount was strongly associated with avoidance of or delays in emergency care. Further research is needed to determine whether these responses reflect greater efficiency or harmful decisions.

Adult↗
PubMedDate not supplied

The impact of increased cost sharing on Medicaid enrollees.

Many state Medicaid programs are implementing cost-saving mechanisms, but little is known about the impact of those strategies on low-income people. Recent increases in cost sharing for Oregon Health Plan (OHP, Oregon's Medicaid program) members have created a natural experiment that is ideal for examining such impacts. Early results from an ongoing cohort study suggest that cost-sharing increases led to a large reduction in OHP membership. Those who left OHP because of the cost-sharing increase reported inferior access to needed care, used primary care less often, and used hospital emergency rooms more often than those who left OHP for other reasons.

Adult↗
PubMed1996

The effect of cost sharing on the use of chiropractic services.

OBJECTIVES: Chiropractic care is increasing in the United States, and there are few data about the effect of cost sharing on the use of chiropractic services. This study calculates the effect of cost sharing on chiropractic use. METHODS: The authors analyzed data from the RAND Health Insurance Experiment, a randomized controlled trial of the effect of cost sharing on the use of health services. Families in six US sites were randomized to receive fee-for-service care that was free or required one of several levels of cost sharing, or to receive care from a health maintenance organization (HMO). Enrollees were followed for 3 or 5 years. All fee-for-service plans covered chiropractic services. Persons assigned to the HMO experimental group received free fee-for-service chiropractic care; persons in the HMO control group had 95% cost sharing for chiropractic services. The authors calculated the mean annual chiropractic expense per person in each of the fee-for-service plans, and also predicted their chiropractic expenditures using a two-equation model. Chiropractic use among persons receiving HMO and fee-for-service care were compared. RESULTS: Chiropractic care is very sensitive to price, with any level of coinsurance of 25% or greater decreasing chiropractic expenditures by approximately half. Access to free chiropractic care among HMO enrollees increased chiropractic use ninefold, whereas access to free medical care decreased fee-for-service chiropractic care by 80%. CONCLUSIONS: Chiropractic care is more sensitive to price than general medical care, outpatient medical care, or dental care, or and nearly as sensitive as outpatient mental health care. A substantial cross-price effect with medical care may exist.

Adult↗
PubMed2003

Cost sharing for substance abuse and mental health services in managed care plans.

Recent initiatives to improve private insurance coverage for substance abuse and mental health in the United States have mostly focused on equalizing coverage limits to those found in general medical care. Federal law does not address cost sharing (copayments and coinsurance), which may also deter needed care or impose significant financial burdens on enrollees. This article reports on cost sharing requirements for outpatient care in a nationally representative sample of managed care plans in 1999. Levels of cost sharing are substantial, with around 40 percent of products requiring copayments of $20 or more and another 15 percent requiring coinsurance of 50 percent. Cost sharing for outpatient substance abuse treatment is very similar to that for mental health. Compared to general medical care, at least 30 percent of products impose higher cost sharing for substance abuse and mental health treatment. Future parity initiatives should be examined for how they address differences in cost sharing as well as limits.

Cost Sharing↗
PubMed2003

Drug and alcohol treatment among privately insured patients: rate of specialty substance abuse treatment and association with cost-sharing.

OBJECTIVE: To examine the rate of formal substance abuse (SA) treatment in a privately insured population, and the association between cost-sharing, residential treatment, and outpatient SA treatment, we analyzed claims data for 332442 adults in 41 health plans with comprehensive SA treatment benefits. DESIGN: SA treatment utilization during 1999 and the relationship between patient cost-sharing, gender, and SA diagnosis on SA treatment utilization were examined using a cross-sectional retrospective analysis. RESULTS: Only 0.37% (n=1230) of adults had a SA related claim during 1999. Individuals in plans with higher levels of cost-sharing had lower rates of residential SA treatment and specialty SA outpatient treatment compared to individuals in plans with lower cost-sharing, adjusting for age, sex, and SA diagnosis. CONCLUSIONS: Few individuals had SA related claims, raising questions about rates of undocumented treatment, out-of-network treatment, and unmet need for treatment in the privately insured, and its implications for assessing the quality of SA treatment available in private health plans. At a time when levels of cost-sharing are increasing among privately insured individuals, consideration should be given the potential impact of such changes on the treatment of individuals requiring specialty SA treatment.

Adult↗