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Study Objectives: Insufficient sleep costs the US economy over $411 billion per year. However, most studies investigating the economic costs of sleep rely on one-time measures of sleep, which may be prone to recall bias and cannot capture variability in sleep. To address these gaps, we examined how sleep metrics captured from daily sleep diaries predicted medical expenditures., Methods: Participants were 391 World Trade Center (WTC) responders enrolled in the WTC Health Program (mean age = 54.97 years, 89% men). At baseline, participants completed 14 days of self-reported sleep and stress measures. Mean sleep, variability in sleep, and a novel measure of sleep reactivity (i.e. how much people's sleep changes in response to daily stress) were used to predict the subsequent year's medical expenditures, covarying for age, race/ethnicity, sex, medical diagnoses, and body mass index., Results: Mean sleep efficiency did not predict mental healthcare utilization. However, greater sleep efficiency reactivity to stress (b = $191.75, p = .027), sleep duration reactivity to stress (b = $206.33, p = .040), variability in sleep efficiency (b = $339.33, p = .002), variability in sleep duration (b = $260.87, p = .004), and quadratic mean sleep duration (b = $182.37, p = .001) all predicted greater mental healthcare expenditures. Together, these sleep variables explained 12% of the unique variance in mental healthcare expenditures. No sleep variables were significantly associated with physical healthcare expenditures., Conclusions: People with more irregular sleep, more sleep reactivity, and either short or long sleep engage in more mental healthcare utilization. It may be important to address these individuals' sleep problems to improve mental health and reduce healthcare costs., (© The Author(s) 2024. Published by Oxford University Press on behalf of Sleep Research Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Health financing in Ghana aims for universal access to healthcare, with both public and private insurance schemes playing vital roles. The National Health Insurance Scheme (NHIS) addresses out-of-pocket expenses but faces enrollment and trust issues. However, 12 licensed Private Health Insurance Schemes (PHISs) offer complementary services, enhancing healthcare access and quality through additional coverage and service delivery. This study aimed to assess the operations and performance of PHIS in Ghana., Methods: The research utilized a qualitative descriptive design, focusing on registered PHIS providing services to Ghanaians. A convenient sampling technique was employed for data collection. Data was gathered through face-to-face interviews with participants until saturation was achieved. The data was thematically analyzed., Results: The study highlights the intricate regulatory framework governing PHISs in Ghana, emphasizing licensing and accreditation requirements. It revealed diverse operational strategies, including nationwide coverage and tailored policies for different clientele. Benefit packages varied, with distinct plans like the "X-scan plan" for medical imaging. Payment structures ranged from upfront payments to flexible options. PHIS's growth was driven by health concerns during the COVID-19 pandemic, strategic investments, and partnerships. Clientele for PHIS primarily resides in urban areas, focusing on sectors like education., Conclusion: The study assesses Ghana's PHI sector, highlighting its critical role in financing healthcare in Ghana. Findings reveal PHIS's diverse packages and flexible payments boost healthcare access and quality. We, therefore, recommend PHIS foster partnerships with National Health Insurance Authority (NHIA) accredited facilities, reduce non-payment risks, and ensure transparency to foster trust and accurate risk assessment, promoting sustainable growth and reliability in Ghana's Private Health Insurance (PHI) industry., Competing Interests: Declarations. Ethical approval and consent to participate: Ethical approval was obtained from the Committee on Human Research, Publication, and Ethics at the Kwame Nkrumah University of Science and Technology with reference number CHRPE/AP/849/23. The study was conducted in accordance with the Declaration of Helsinki. Consent was obtained from all participants, who were fully informed of the study’s context and the intended use of the data. To ensure confidentiality, the data was anonymized. Participation was voluntary and participants could opt out of the study when they wanted to. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Multiple chronic conditions (MCC) have become a leading cause of low vitality and high mortality among the Chinese population. Although a series of policies has been implemented to promote patients' rational access to health care, patients still prefer a higher level of inpatient service, hampering the efficient utilization of resources in county hospitals, which are the first point of contact for inpatient care. Thus, this study aimed to identify the factors that affect MCC patients' inpatient preferences and the extent to which these factors influence their decisions, thereby guiding inpatient service utilization among MCC patients., Methods: Five attributes (institution scale, waiting time for hospital admission, presence of acquaintances, travel time from residence to hospital, and out-of-pocket expenses per visit) were identified to estimate inpatient choice for MCC patients through a discrete choice experiment. A partial factor analysis was performed to generate selection sets. Data were collected from MCC patients aged between 35 and 75 years, in Fuqing City, China. A mixed logit model was used to analyse MCC patients' preferences for each attribute. Willingness to pay was estimated by regression coefficients, and interaction terms were included in the model to estimate the heterogeneity of inpatient preferences among MCC patients., Results: A total of 504 valid questionnaires were included in the analysis. The most important attribute of patients when choosing inpatient care is out-of-pocket expenses per visit, followed by travel time from residence to hospital, waiting time for hospital admission, institution scale, and presence of acquaintances. In addition, patients were willing to pay ¥1253, ¥434, and ¥323 for shorter times from the residence to the hospital, larger institutional scale, and beds available on the day, respectively. The findings of the interaction analysis indicated that age and gender also influence MCC patients' inpatient preferences., Conclusion: This study provides evidence of the inpatient preferences of MCC patients. Increasing inpatient insurance reimbursement rates, bolstering the leading role of district and county hospitals in the area, and strengthening information systems will empower district and county hospitals to effectively serve as the first point of contact for inpatient care., Competing Interests: Declarations. Ethics approval and consent to participate: This research was approved by the Biomedical Research Ethics Review Committee of Fujian Medical University (No. 2021 − 154) and (No. 2021 − 109). This study was conducted under the Declaration of Helsinki. Informed consent was obtained from all individual participants included in the study. All participants were informed about the study purpose, participation in the study was voluntary, and all responses were anonymous. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

India's economy is among the fastest growing in the world. However, a large share of informal workforce is a common characteristic of country's economy, comprises a significant portion of most of its labour markets. This workforce often receives low wages and lacks benefits such as strong social security and health coverage for all. The majority of healthcare spending in India is private. As India's population ages and the informal sector expands, it is expected that many of these workers will continue to work beyond the retirement age to bear their own healthcare costs due to lack of savings, pensions, and the precarious nature of their employment. In this context, this study estimates the burden of out-of-pocket (OOP) payments on India's informal older workers compared to their formal counterparts, using data from the first wave of the nationally representative Longitudinal Ageing Study in India. According to estimates from the two-part regression model, informal older workers pay, on average, INR 1113 (P < 0.01) and INR 55 (P < 0.05) less than their formal counterparts for inpatient and outpatient care, respectively. Further, probit regression models revealed that the burden of combined (both inpatient and outpatient) OOP payments exceeding (by 40, 20 and 10%) of their income is significantly higher among informal older workers compared to formal older workers. The study underscores the need for strengthening of universal health insurance schemes to ensure everyone has access to medical services without experiencing financial hardship. It also advocates for policies specifically tailored towards informal workers, considering their unique challenges with regard to livelihoods and healthcare security. In particular, this encompasses bolstering the existing social security and healthcare system, and related policies for ensuring financial security against OOP payments, especially for informal workers and all the population in general., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

This study explores the effect of the transformation of paediatric healthcare through the implementation of the Family Mutual Aid System (FMAS) for personal medical insurance accounts among paediatric patients at a children's hospital (Hospital A in Shanghai, China). We conducted a cohort study in the endocrinology department of Hospital A from August 2021 to July 2023 to assess the impact of FMAS enrolment on patients' annual outpatient visits, annual outpatient expenditures, and the allocation of these costs among the basic medical insurance pooling fund and patients' out-of-pocket expenses, with a further subdivision into online and offline consultations. Analysis employed a weighted difference-in-differences approach within a fixed-effects model following propensity score matching. The study encompassed 10 975 paediatric patients, divided into those enrolled in FMAS (observation group) and those not (control group). Enrolment in FMAS was associated with a statistically significant increase in annual outpatient visits by an average of 1.107, predominantly attributed to an uptick in offline consultations. Additionally, there was a substantial 38.9% rise in annual outpatient costs. Detailed analysis revealed a 52.5% increase in costs covered by the medical insurance pooling fund, while patients' out-of-pocket expenses decreased by an average of 69.2%. These findings highlight the beneficial effects of FMAS enrolment on healthcare service utilization and the risk-sharing mechanisms of medical insurance., (© The Author(s) 2024. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

Generic substitutions are globally considered to contain health expenditures. Yet it is uncertain whether the costs spill over to other medicines or health services. Contextualizing China's National Volume-Based Procurement (NVBP) policy, which promoted generic substitution, this study tests the changes in patients' utilization of generic medicines and whether the costs shift to other pharmaceutics or health services post-policy. This population-based, matched, cohort study uses claims data from Tianjin, China in 2018-2020. We focus on amlodipine, the most commonly used calcium channel blocker with the largest procurement volume. We build comparable post-policy cohorts: Non-switchers who kept using originator amlodipine, Pure-switchers who loyally switched to generic amlodipine, and Back-switchers who switched back-and-forth; and compare between each matched pair, respectively, their annual healthcare costs and that broken down by components, and patients' use of and adherence to amlodipine post-policy. In all, 1185 Pure-switchers, 1398 Back-switchers, and 2330 Non-switchers were identified (mean age: 63.0 years; 58.5% men). For the matched pairs, Pure-switchers (n = 772) incurred annual total medical costs of CNY 9213.5, 12.2% lower than Non-switchers [n = 1544, absolute difference CNY -1309.3, 95% confidence interval (-2645.8, -19.6)]. The cost reduction only results from amlodipine prescriptions in outpatient encounters and are equally borne by health plans and the enrolees. The costs for Pure-switchers and Non-switchers are not different from other medicines, nor from other items including tests, surgeries, beds, and medical consumables for hypertension-related encounters/admissions. Pure-switchers also had higher daily dosage and better adherence to amlodipine than Non-switchers. The differences between Back-switchers and Non-switchers show similar trends but are less profound. China's NVBP policy is effective in controlling pharmaceutical costs. No unintended cost effects have yet been identified in the short run. Other countries may learn from China on a comprehensive set of auxiliary policies, including listing, bidding, purchasing, and reimbursing, to better promote generic substitutions., (© The Author(s) 2025. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.)

As expensive therapeutics rise to the fore of heart failure management, out-of-pocket (OOP) medication costs have become increasingly relevant to patient care. Prescription medication costs influence medical decision-making and affect adherence. Yet, individualized cost estimates are seldom available during clinical encounters when prescription decisions are made. The lack of transparency around medication costs prohibits cost-sensitive shared decision-making and can lead to financial toxicity and delays in therapeutic management. Upcoming policy changes will affect the availability and affordability of heart failure medications in the United States, such as the implementation of a $2,000 cap on OOP drug spending for Medicare Part D Plans in 2025. This state-of-the-art review summarizes the current landscape of cost transparency efforts using heart failure management guidelines and the U.S. health care system as an illustrative example. Understanding the variables involved in determining medication costs and the resources available to reduce OOP cost are paramount for heart failure clinicians and their patients worldwide., Competing Interests: Funding Support and Author Disclosures Dr Allen has received consulting fees from ACI Clinical, the American Heart Association, Boston Scientific, Quidel, and UpToDate. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Published by Elsevier Inc.)

Introduction/aims: Claims-based analyses have demonstrated high medical costs associated with myasthenia gravis (MG). We examined the economic burden of MG from the perspective of affected people and their families., Methods: The Muscular Dystrophy Association developed and conducted an online survey of people with MG and their caregivers between October 26 and December 6, 2021. Major themes were: MG-associated financial decisions, quality of life, employment and direct/indirect costs of diagnosis, healthcare insurance, medical visits, medications/treatments, medical equipment/devices, and caregiving., Results: Eight hundred people with MG and 238 caregivers responding on behalf of a person with MG completed the survey. Most respondents were white (85%) and about half (55%) had received a 4 year college degree or higher education. Respondents indicated that MG impacted their health, recreation, and finances. 70% reported making financial adjustments or seeking financial assistance. Annual out-of-pocket costs (mean, $15,798; median, $7750) were primarily driven by medications, cost to receive a diagnosis, and healthcare insurance premiums. People receiving infusions paid significantly more across all care domains. Demographic disparities were observed, with people of color, women, and those on disability paying significantly more to receive a diagnosis than their counterparts., Discussion: The economic burden on people with MG and their families is substantial, primarily driven by direct costs. There is a need to engage more broadly with the MG community for generalizable information. Respondents were self-selected, which may impact results. The results will be used to educate the public and inform advocacy work, with the goal of improving the lives of people with MG., (© 2024 Wiley Periodicals LLC.)

Background: Despite the proliferation of exercise referral schemes in the UK, evidence on their efficacy is equivocal. The Welsh National Exercise Referral Scheme (NERS) is heavily used but inequalities in uptake have been reported. As a result of the COVID-19 pandemic, NERS was initially suspended and then transitioned from standard face-to-face delivery to alternative remote methods, including virtual delivery. The aim of this study was to explore the barriers and facilitators to uptake and engagement of NERS when delivered in face-to-face and virtual formats, and to examine the cost to service users of engaging with the scheme in these different ways., Methods: This was a qualitative study with supplementary cost analysis. Maximum variation sampling was used to recruit participants. Interviews with service users (n = 21) and one person who declined the service, and three focus groups with service providers (n = 19), were conducted. Framework analysis was used to analyse the qualitative data. Quantitative data obtained through the interviews on service users' out-of-pocket costs of attending face-to-face or virtual classes were summarised using descriptive statistics., Results: Five themes were identified from the qualitative analysis which summarised barriers and facilitators to uptake and engagement as perceived and experienced by the different stakeholders. Themes included: opaqueness and uncertainty around referral; Exercise Referral Professionals allaying concerns and providing reassurance at scheme entry; the mixed appeal and accessibility of virtual delivery; factors that support ongoing engagement; and personal and financial circumstances restricting uptake and engagement., Conclusions: This study indicates that offering a virtual version of NERS could make the scheme more accessible to those who are typically underserved, provided strategies to address digital inclusion are addressed. Findings provide wider evidence to inform adaptations that could be made to ensure that other exercise referral schemes can optimise virtual delivery., Competing Interests: Declarations. Ethical approval and consent to participate: All participants provided informed consent prior to data collection. Ethical approval was granted by the University of Hertfordshire’s Health Science Technology and Engineering Ethics Committee with Delegated Authority (ECDA; Protocol number: aLMS/SF/UH/04546(3). This study was conducted according to the principles expressed in the Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: This PHIRST evaluation was initiated following submission of an expression of interest to the funder by Public Health Wales, with partnership working between this initiator and the research team encouraged by the funder. MAM and AP are employed by Public Health Wales and have strategic oversight of NERS. They are included as co-authors to fairly reflect their involvement in conceiving the research and supporting preparation of the manuscript. There was no undue influence by MAM or AP in any aspect of the research and all study conclusions were reached independently. Other authors declare that they have no competing interests., (© 2025. The Author(s).)

Objective: To descriptively analyse Australian public sector General Mental Health Services (GMHS) expenditure, ambulatory, and inpatient services, including key performance indicators (KPIs) in comparison with other subspeciality mental health services (MHS)., Method: We descriptively analysed data published by the Australian Institute of Health and Welfare (AIHW), including inpatient, ambulatory services, expenditure, and KPIs., Results: From 2017-18 to 2021-22, per capita expenditure for Australian GMHS (18-64) rose by an average annual inflation-adjusted change of 2%. Overall bed numbers remained static, with non-acute beds declining, and commensurate expansion of acute beds. Community GMHS had high outpatient utilisation, with high rates of schizophrenia, schizoaffective disorder, and bipolar affective disorders as primary diagnoses in mid-life. From 2017-18 to 2021-22, GMHS inpatient and ambulatory episodes had decreasing rates of significant improvement and increasing rates of significant deterioration., Conclusions: Although GMHS has the highest overall population and service utilisation, there has been static bed availability and relatively small increases in expenditure which are occurring concurrently with worsening clinical outcomes. Evidence-based modelling of GMHS and outcomes is required to inform future service improvement., Competing Interests: DisclosureThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: SA, TB, SK and JL are members of the editorial team for the journal, and they were not involved in the independent peer-review of this paper. HC and MB declare no conflicts of interest.

Objective: To examine the association between hospital-cardiologist integration and Medicare spending for stable angina patients., Data Sources and Study Setting: This study used Medicare Standard Analytic Files from 2013 to 2020 and the Centers for Medicare and Medicaid Services National Downloadable File for accompanying physician data., Study Design: This was a retrospective cohort study of Medicare beneficiaries with a new diagnosis of stable angina between 2013 and 2020., Data Collection/extraction Methods: Patients with a new diagnosis of stable angina were categorized by whether they received care from an independent or a hospital-integrated cardiologist., Principal Findings: Total spending for this sample was high: an average of $103,946 per patient over 12 months. Adjusted for covariates, patients of integrated cardiologists did not spend significantly more or less than clinically comparable patients of independent cardiologists (-$3856, 95% CI: -$8631 to 920, p = 0.11). This was true for overall inpatient (-$2622, 95% CI: -6069 to 825, p = 0.14) and outpatient (-1162, 95% CI: -$3510 to 1185, p = 0.33) spending as well as cardiology-specific inpatient and outpatient spending. Among high-risk patients, overall spending between the integrated and independent groups was comparable, though patients of integrated cardiologists incurred lower spending than those of their independent counterparts in inpatient care (-$13,589; 95% CI: -24,432 to -2746, p = 0.01). In a supplemental analysis, findings suggested that site-neutral payments would have resulted in lower spending among patients of integrated physicians., Conclusions: Specific clinical settings may lend themselves to efficiencies created by integration for certain complex patients, though we do not test a causal mechanism here. Adoption of site-neutral payment policy may also lead to lower spending among patients of integrated physicians., What Is Known on This Topic: Hospital-physician integration has increased significantly in the United States. Policymakers and health policy experts have expressed concerns that hospital-physician integration leads to increased health spending and may threaten healthcare affordability. While some studies link integration to greater spending, many use incomplete measures of spending, do not consider the potential benefits of care coordination, or rely on outdated data., What This Study Adds: Spending among patients with stable angina, a common cardiovascular condition, was nearly equal, on average, across patients of integrated and independent cardiologists. Inpatient spending on high-risk patients was somewhat lower for those under the care of integrated cardiologists. Overall, patients of integrated cardiologists incurred largely comparable spending relative to patients of independent cardiologists, indicating that the impact of hospital-physician integration may depend on the clinical context., (© 2024 The Author(s). Health Services Research published by Wiley Periodicals LLC on behalf of Health Research and Educational Trust.)

Objective: To investigate the effects of the Affordable Care Act (ACA) and its elimination of cost sharing on contraception utilization, pregnancy rates, and abortion rates., Methods: We conducted a retrospective cohort study within a health care system serving more than 4.5 million insured members across 21 medical centers and 250 clinics. The study included women aged 18-45 years with continuous health plan membership for at least 2 years in the pre-ACA (2007-2012) and post-ACA (2013-2018) periods. We analyzed out-of-pocket (OOP) costs for contraception, including oral contraceptives and long-acting reversible contraception (LARC), before and after the ACA's implementation. We then examined how the elimination of OOP costs affected contraception use, pregnancy rates, and abortion rates., Results: The study identified 1,523,962 women of childbearing age. In 2013, cost sharing for contraception sharply declined, with average annual OOP costs dropping from $88-94 pre-ACA to nearly zero post-ACA. Contraceptive use increased overall, rising from 30.2% pre-ACA to 31.9% by the study's end, with a notable rise in LARC use. In interrupted time-series analyses, contraception use continued to increase post-ACA, new pregnancy rates declined at a faster rate than pre-ACA, and abortion rates continued to fall, though at a slightly slower pace than pre-ACA ( P <.05 for all trends)., Conclusion: The ACA's elimination of contraception cost sharing led to increased contraception use, particularly LARC methods, and contributed to declines in both pregnancy and abortion rates. This suggests that improving access to effective contraception is a key strategy in reducing unintended pregnancies., Competing Interests: Financial Disclosure Matthew Solomon reports his institution received funding from Kaiser Permanente Community Health. Mary Reed reports her institution received funding from Kaiser Permanente Community Health, NIDDK, NIA, and the AHRQ. They also received a PCORI grant. The other authors did not report any potential conflicts of interest., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.)

Objectives: Current, real-world healthcare cost information is needed to project future expenditures and inform policy. We estimated the healthcare costs for adults in 2019 in the United States by age, sex, race/ethnicity, geographic region, and comorbidity., Methods: We aggregated and summarized the healthcare costs in 2021 US dollars using claims data derived from Optum's deidentified Clinformatics® Data Mart Database, which includes inpatient, outpatient, and prescription claims for commercial and Medicare Advantage beneficiaries nationwide., Results: A total of 9 227 901 adults were included in the analysis. The largest group represented was 71 to 75 years old (13%), female (53%), White (68%), received care in the South (41%), and had commercial health insurance (56%). There was a positive relationship between healthcare cost and age. Females had a 1.3-fold multiplicative increase in costs than males (95% CI 1.33-1.34). There were 92.5% of individuals who had health claims in the Northeast, 89.6% in the Midwest, 88.9% in the South, 77.1% in the West, and 12.7% with unknown geographic region. Patients with severe renal failure, heart failure, or metastatic cancer incurred the highest mean yearly costs ($139 844, $113 031, and $85 299, respectively). Metastatic cancer and severe renal failure were associated with a 5.3-fold multiplicative increase in costs than not having these conditions, after adjusting for potential confounders (95% CI 5.26-5.41 and 4.98-5.16, respectively)., Conclusions: We identified patient characteristics and medical conditions that are associated with high healthcare cost burden and could benefit from tailored interventions. We provided detailed cost estimates to aid healthcare modeling, cost projection, and cost-minimizing interventions., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2025. Published by Elsevier Inc.)

Objective: This report describes characteristics of patients who had high out-of-pocket (OOP) spending on mental health care relative to income., Methods: A sample of 8,923 U.S. adults with outpatient mental health visits was drawn from the 2018-2021 Medical Expenditure Panel Survey. Respondents who spent ≥10% of their disposable family incomes on OOP mental health visits were defined as having a high OOP cost burden., Results: Using weighted percentages, the authors found that 2.4% of psychiatric outpatients had a high OOP burden; among those below the federal poverty level, 12.8% had a high OOP burden. Patients with a high (vs. low) OOP burden were statistically significantly more likely to be uninsured (7.5% vs. 2.4%) or diagnosed as having a substance use disorder (8.7% vs. 2.8%) or bipolar disorder (14.5% vs. 8.0%)., Conclusions: Despite federal policies extending the availability of insurance for mental health care, many low-income psychiatric outpatients experience high OOP cost burden., Competing Interests: The authors report no financial relationships with commercial interests.

Background: In Japan, medical expenses for COVID-19 treatment transitioned from full public funding support to out-of-pocket (OOP) payment by patients plus partial public support in October 2023, and public support fully ended in March 2024. This study evaluated the clinical and economic impacts of initiating OOP payments., Research Design and Methods: To assess the impact on prescription rates, we compared the prescription rates of antivirals from the 4-month pre- to post-OOP payment initiation period using a claims database. Subsequently, a budget impact model assessed the impacts of a hypothetical decline in the prescription rates on COVID-19-related hospitalizations, deaths, and direct medical costs for antiviral prescription and hospitalization., Results: The antiviral prescription rate per 100 patients decreased from 17.5 for the pre-OOP payment initiation period to 11.5 for the post-OOP payment initiation period, that is, a change of - 34.3%. With prescription rate decreases of 40%, 60%, and 80%, the hospitalizations would increase annually by 22,533 (3.3%), 33800 (5.0%), and 45,066 (6.6%), respectively. The total costs would increase by JPY9.5 billion (USD67.3 million; 0.7%), JPY14.3 billion (USD100.9 million; 1.0%), and JPY19.0 billion (USD134.5 million; 1.3%), respectively., Conclusions: Higher OOP payment decreased the antiviral prescription rate, potentially leading to clinical and economic loss.

Introduction: Rheumatoid Arthritis (RA) is among the most prevalent chronic inflammatory diseases affecting millions of people with a significant expenditure of resources by National Healthcare Systems. This study aimed to analyze all available treatments exclusively for RA to highlight the costs of each treatment type and raise awareness of the use of biosimilar drugs., Methods: In an Italian healthcare authority, all prescriptions made for the diagnosis of RA were extracted to verify consumption expressed in Defined Daily Dose (DDD) and the expenditure incurred expressed in euros. Consequently, a grouping into three major drug categories has been performed: anti - tumor necrosis factor alpha agents (TNFα), other injectable formulations, and novel oral formulations., Results: Prescriptions for the second half-year 2022 and 2023 have been analyzed, with a total cost of almost 7 million euros in the sample considered. All pharmaceutical categories showed an increase in consumption, but only anti- TNFα recorded a decrease in costs from 25% in 2022 to 22% in 2023, thanks to the lower cost of the biosimilar drug., Conclusion: The costs of RA may represent a significant spending commitment for central governments. As a result, actions are needed to encourage the preferential use of biosimilar drugs.

Background: The largest proportion of people at risk of catastrophic expenditures for surgical care live in low- and middle-income countries. This study aims to evaluate the financial impact among surgical patients at Kibuye Hope Hospital (KHH) in Burundi., Methods: Data were collected from patients undergoing a surgical procedure at KHH from January to October 2019. A predesigned questionnaire was used to collect information regarding socio-demographics, pre-hospital and hospitalization characteristics, finances, and surgical outcomes. Out-of-pocket (OOP) health expenditure, catastrophic health expenditure (CHE), impoverishing health expenditure (IHE), and financial distress (FD) were summarized., Results: Of a total of 301 patients, 60% lived below the extreme poverty line ($2.15) at baseline. After surgery, 66% of patients faced CHE, 66% faced FD, and 73% faced IHE. Almost all patients (94%) reported having an insurance plan, although the rate of OOP expenditure was high (98%). The median cost of medications ($215.5) or surgery ($305.6) surpassed the median monthly household expenditure allocated to food ($183.4). The proportion of patients facing extreme poverty at baseline increased from 60% to 96% after direct medical expenses. Many patients reported borrowing money (30%) or selling their land/possessions (46%) to cover OOP expenses., Conclusions: Most surgical patients at KHH face extremely high risks of CHEs and impoverishment due to OOP expenses for care, despite insurance coverage. The risk of families being forced into poverty and experiencing FD from surgical care are indicators of the lack of effective financial risk protection programs in Burundi., (© 2024 International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Background: Mental illnesses can cause mental health (MH) impairments such as decreased interest and generalized fatigue. MH impairments can adversely affect oral health. The aim of this study was to investigate the associations between MH impairment, MH care, and oral health care use., Methods: This cross-sectional study used nationally representative data of US adults from the 2017-2021 Medical Expenditure Panel Survey. Pearson χ 2 test and logistic regressions were used to assess the associations between oral health care use and MH impairment and oral health care use and MH care use. Regressions controlled for age, sex, race and ethnicity, income, education, survey year, marital status, geographic region, and dental insurance status., Results: MH impairment was associated with lower odds of using any dental care (odds ratio [OR], 0.85; 95% CI, 0.81 to 0.90) and preventive care (OR, 0.79; 95% CI, 0.74 to 0.84) and with higher odds of oral surgery (OR, 1.32; 95% CI, 1.20 to 1.46) use. Receiving MH care was associated with higher odds of using overall dental care (OR, 1.62; 95% CI, 1.43 to 1.82; P < .001), preventive care (OR, 1.72; 95% CI, 1.52 to 1.96; P < .001), and restorative care (OR, 1.26; 95% CI, 1.05 to 1.50; P = .01) use., Conclusions: MH impairment was associated with lower odds of preventive and overall dental care use and with higher odds of oral surgery use. For adults with MH impairment, receiving MH care was associated with higher odds of preventive, restorative, and overall dental care use., Practical Implications: Mental illness can be a barrier in accessing preventive dental care. However, MH care service may aid in increasing preventive, restorative, and overall oral health care use., Competing Interests: Disclosures None of the authors reported any disclosures., (Copyright © 2025 American Dental Association. Published by Elsevier Inc. All rights reserved.)

Aims and Objectives: Approximately 50% of Americans report having low health insurance literacy, leading to uncertainty when choosing their insurance coverage to best meet their healthcare needs. Therefore, we aimed to evaluate the association between lack of prescription drug benefit knowledge and problems paying medical bills among Medicare beneficiaries., Methods: We analysed the 2021 Medicare Current Beneficiary Survey Public Use File of 5586 Medicare beneficiaries aged ≥ 65 years. The binary dependent variable was whether beneficiaries had problems paying medical bills in the past year. The categorical independent variable was how much beneficiaries knew about the Medicare prescription drug benefit. A survey-weighted multivariable logit model, adjusted for covariates (e.g., socio-demographics, comorbidities, private insurance coverage, and satisfaction with out-of-pocket costs), was conducted to examine the association between the independent variable and problems paying medical bills., Results: Approximately 4.3% of study beneficiaries (~2.0 million beneficiaries) reported problems paying medical bills. Of those without and with problems paying medical bills, 27.7% and 39.6%, respectively, reported knowing little/almost nothing about prescription drug benefits. Beneficiaries aged 65-74 years (marginal effect [ME] = 2.1%, p < 0.01), with comorbidities (e.g., ≥ 4 conditions, ME = 3.8%, p < 0.001), dissatisfaction with out-of-pocket costs (ME = 10.1%, p < 0.001), without private insurance (e.g., employer-sponsored insurance, ME = 2.5%, p < 0.01), or with little/almost no knowledge of prescription drug benefits (ME = 1.9%, p < 0.05) were more likely to report problems paying medical bills compared to their counterparts., Conclusion: Tailored programmes aimed at improving beneficiaries' knowledge of prescription drug benefits, reducing out-of-pocket costs and preventing comorbidities may be considered for the at-risk population to address the problem., (© 2024 John Wiley & Sons Ltd.)

Background: Respiratory syncytial virus (RSV) is a major cause of pediatric respiratory tract infections. In Japan, children with specific underlying conditions are eligible to receive palivizumab to prevent severe RSV disease. However, the association between palivizumab eligibility and RSV infection severity remains unclear. This study examined RSV infection severity and hospitalization outcomes in Japanese infants and children according to palivizumab eligibility and identified their associated factors., Methods: Using insurance claims data from 12 municipalities, we identified RSV cases in children ≤24 months of age between April 2017 and March 2022. The patients' characteristics and hospitalization status were analyzed according to the presence of palivizumab-indicated underlying conditions. Regression models were used to identify factors associated with hospitalization, length of stay (LOS), and hospital expenditures., Results: We analyzed 1025 first-time RSV cases (860 infants <12 months and 165 children 12-24 months old). There were 777 (90.3%) palivizumab-ineligible infants and 83 (9.7%) palivizumab-eligible infants. Only 13 (15.7%) palivizumab-eligible infants had received palivizumab in the month before RSV infection, and 8 required hospitalization. RSV hospitalization was significantly associated with age (odds ratio: 0.84, 95% confidence interval: 0.79-0.88), palivizumab-indicated underlying conditions (1.82, 1.13-2.89), and non-indicated high-risk conditions (4.87, 2.28-10.99). These factors were also associated with LOS. Hospital expenditures were associated with age, high-risk conditions and LOS., Conclusions: Palivizumab-indicated underlying conditions, high-risk conditions, and younger age are risk factors for RSV hospitalization. Most hospitalized patients did not receive palivizumab in the month before RSV infection despite being eligible, suggesting that some hospitalizations were preventable through appropriate palivizumab use., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Objective: To examine the relationship between market dynamics, in the form of commercial prices paid to urologists, and utilization of services, as measured by Medicare spending, in men with newly diagnosed prostate cancer., Methods: We performed a retrospective national cohort study of Medicare beneficiaries with newly diagnosed prostate cancer between 2014 and 2019, with follow-up through 2020. The primary exposure was the commercial price index (ie, the ratio of commercial prices to Medicare prices for a common set of services performed by urologists). The primary outcome was Medicare spending for prostate cancer in the 12-month period after diagnosis., Results: Across zip codes, commercial prices were, on average, 190% of Medicare prices (range 102%-421%), with mean spending per beneficiary of $16,704. There was an inverse relationship between the price index and Medicare spending for men for prostate cancer. Specifically, standardized Medicare spending was $1485 (95%CI $939 to $2030) higher per beneficiary among those managed in zip codes at the bottom decile for commercial prices compared to the top decile. This effect was similar in the subgroup of men who underwent treatment, where standardized Medicare spending was $1461 (95%CI $848 to $2073) higher per beneficiary among those managed in zip codes in the bottom decile for commercial prices compared to the top decile., Conclusion and Relevance: Commercial prices for a set of frequently performed services are substantial higher than those paid by Medicare and vary widely across zip codes. Higher commercial prices were associated with significantly lower utilization, as measured by standardized Medicare spending, in men with newly diagnosed prostate cancer., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. All authors have no conflicts of interest to report., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objectives: To study the national trends of anticoagulants, antiarrhythmic drugs (AADs), and expenditures in the civilian noninstitutionalized atrial fibrillation (AF) population., Methods: The Medical Expenditure Panel Survey was queried from January 2016 to December 2021 to identify adults (age ≥18 years) with a diagnosis of AF utilizing the International Classification of Diseases, Tenth Revision, Clinical Modification code I48. Prevalence of anticoagulants (AAD) and its expenditure and AF expenditure across clinical settings in the United States were estimated. The predictors of anticoagulant use were identified utilizing multivariate logistic regression analysis., Results: A total of 17.3 million AF adults were identified, of which 46.5% were female, 89.6% were White, and ∼70% were middle/high income with prevalent comorbidities of hypertension (75.3%) and coronary heart disease (30%). The mean CHA 2 DS 2 VASc score was 3.2, and 40% had a score of ≥4. In the United States, an average of $26 103 (2021 inflation adjusted) was spent per year per adult with AF for health-related expenditures. The prevalence of direct oral anticoagulants (DOACs) and class I AAD use has increased; in contrast, vitamin K antagonists use has declined. DOAC-related per person annual expenses increased from $849 in 2016 to $1929 in 2021. In those with a CHA 2 DS 2 VASc score of ≥2, female sex and the presence of coronary heart disease were associated with a lower likelihood of anticoagulant use., Conclusions: AF is a costly condition in which prescription medication use, such as DOACs and class III AADs, are significant contributors., Competing Interests: Author Disclosures Author disclosure forms can be accessed below in the Supplemental Material section., (Copyright © 2025. Published by Elsevier Inc.)

Background: As the deadline for the Sustainable Development Goals approaches, financial protection in Cambodia remains inadequate, especially for nonpoor informal workers lacking formal social health protection coverage or access to other prepayment schemes. This exposes them to high out-of-pocket health expenditures (OOPE) and related financial hardship. To better understand the drivers behind these expenditures, our study aims to model their healthcare, health, and social determinants and to assess their relative importance., Methods: In 2023, we conducted a cross-sectional multistage clustered sampling survey across seven Cambodian provinces, surveying 3,254 households engaged in informal employment and not covered by any formal social health protection scheme. The survey gathered information on households' use of outpatient and inpatient care and associated OOPE. We employed generalized linear models (GLMs) to analyse the healthcare, health, and social determinants of OOPE and the OOPE budget share (the proportion of total annual household consumption expenditure spent on OOPE) and applied Shapley decomposition analysis to quantify the relative contributions of these determinants to the explained variance in our outcomes., Results: Healthcare variables were the dominant contributors to the explained variance in all outcomes (41.36-50.73%), followed by health factors. While several social variables were significant, only the wealth quintile made notable contributions to explaining variance in our outcomes. The key healthcare contributors included the sector type and level of care, and the number of outpatient medications. Important health contributors included illness severity and the presence of chronic illnesses or noncommunicable diseases., Conclusions: Our findings emphasize the necessity of integrating nonpoor informal workers and their dependents into formal prepayment schemes to reduce OOPE and enhance financial protection on Cambodia's path toward universal health coverage. Strategically engaging with private providers and pharmacies to improve access to essential services and medicines, coupled with the implementation of an effective referral system are important policy considerations to this end. Further research is needed on how health determinants are modifiable with policy interventions. Our findings can assist the Cambodian government in advancing its universal health coverage goals and offer insights for other countries aiming to extend coverage to similar population groups., Competing Interests: Declarations. Ethics approval and consent to participate: The study obtained ethical approval from the National Ethics Committee for Health Research (NECHR) of the Ministry of Health Cambodia (reference number 142) in May 2023, ensuring that all methods and procedures complied with the prevailing guidelines and regulations. Initially, the purpose and procedures of the study were explained to all participants, who were provided with a detailed study information sheet and were informed that they could withdraw from the study at any time without any consequences. Given the study context and local norms, the NECHR approved verbal consent, which was obtained from all participants. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Substantial out-of-pocket (OOP) expenditures push a large portion of the population below the poverty line, especially those residing in rural areas having low incomes. Individuals from economically disadvantaged states in India incur higher healthcare costs for hospitalization in public health centers than do those from more developed states. Economically poorer households in states such as Bihar and Odisha face significantly higher OOP expenditures for hospitalization in public health centers than do those in economically developed states such as Tamil Nadu., Objective: This study aims to compare households by using the wealth index and demographic factors concerning OOP expenditures on medicines for acute and chronic illnesses in Odisha, India., Methodology: A cross-sectional household survey was adopted to conduct the research. Access to medicines focused on OOP expenditures in Odisha is being studied by purposively selecting six districts: Rayagada, Kalahandi, Angul, Keonjhar, Khordha, and Kendrapara. A total of 902 households were surveyed. A stratified random sampling procedure was adopted to select the locations and households. The survey took place from October 2021 to February 2022. The sampled respondents were investigated for acute and chronic illnesses. The software SPSS version 25 was used to analyze the data. The details of the expenditures for the past four weeks were compared with those of medicines and healthcare expenses. Households were categorized into wealthy, middle, and poor classes. The prevalence of acute and chronic illnesses was analyzed in light of the share of medicine expenditures to total household expenditures., Results: Out of 902 surveyed households, 173 (19.2%) spent out-of-pocket (OOP) money on medicines due to acute and chronic illnesses. Among the studied population, 23.7% were affected by acute illness, whereas 10.9% suffered from chronic illness. Wealthy households constituted most of the OOP expenditure (81 wealthy households), whereas 33 poor households also contributed to the OOP expenditure. According to the unadjusted odds ratio (UOR) analysis, wealthy households were 0.25 times less likely to spend more than 50% of their total monthly household budget on medicine than poor households (UOR = 0.25, 95% CI = 0.09-0.65). Similarly, ST households were 0.18 times less likely to spend more than 50% of their money on medicine from their budgets than SC households (UOR = 0.18, 95% CI = 0.04-0.72)., Conclusion: The present study again reveals that capital regions (metropolitan regions) are well protected against OOP expenditures on medicines, but tribal areas are still underserved. The odds ratio reveals a critical positive association between high OOP and poor economic status in households in Odisha. That association must be minimized or nullified for equitable economic and social development., Competing Interests: Declarations. Ethics approval and consent to participate: Yes, an ethical approval from the University of Hyderabad, Institutional Ethics Committee was obtained before the study was conducted. The ethical approval was done in accordance with the Declaration of Helsinki. Informed consent to participate was obtained from all of the participants in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objective: To investigate the evolution of prevalence of catastrophic health expenditure in the Brazilian Federal District at three different times (2003, 2009 and 2018), as well, to identify the composition of outof- pocket expenditure in the respective years., Method: Time series study, using descriptive data from the Family Budget Survey. Prevalence was stratified by consumption quintiles., Results: 754 households were selected as a sample in 2003, 695 in 2009 and 1,000 in 2018. Taking a 10% consumption threshold, prevalence of catastrophic expenditure was 12.3% (95%CI 9.6;14.9) in 2003, 15.3% (95%CI 12.1;18.3) in 2009 and 14.1% (95CI% 11.8;16.2) in 2018. Households with lower income had higher prevalence of catastrophic expenditure. Medicines have a greater burden on expenditure of low-income families., Conclusions: There was an increase in prevalence of catastrophic expenditure in the Federal District. Medicines were the main expense for the poorest families.

Background: To address the health inequity caused by decentralized management, China has introduced a provincial pooling system for urban employees' basic medical insurance. This paper proposes a research framework to evaluate similar policies in different contexts. This paper adopts a mixed-methods approach to more comprehensively and precisely capture the causal effects of the policy. Ultimately, this paper aims to assess the impact of the UPA policy on health inequity., Methods: This study takes the provincial unified reform of basic medical insurance for urban employees in China as an example, uses the China Family Panel Studies (CFPS) data and related policy documents, and adopts the DID-RIF hybrid method to test the impact of the equalization of the medical insurance system on health inequity, by using the interaction term in the DID (Difference-in-Differences) model as the independent variable in the RIF (Recentered Influence Function) to exclude the influence of other interfering variables. In addition, the DID method explores the effects of UPA on medical expenditures, which can guide the improvement of the policy., Results: The empirical results show that the UPA policy increases the likelihood of patients developing chronic diseases within six months. Although factors such as age, gender, and marital status influence the probability of chronic disease, health inequity between income groups after the policy's implementation primarily stems from the rise in outpatient and reimbursement expenses., Conclusions: Although the gap in medical reimbursement expenses between participants of different socioeconomic statuses narrowed after the provincial medical insurance pooling reform, health inequity among the insured population increased. The equalized health insurance reform failed to address health inequities based on socioeconomic status. Additionally, the reverse reallocation of medical resources and outpatient arbitrage driven by moral hazard warrant close attention. This paper recommends that, in advancing the provincial pooling of UEBMI, greater focus should be placed on strengthening digital oversight and improving the hierarchical diagnosis and treatment system to promote social equity., Competing Interests: Declarations. Ethics approval and consent to participate: The study follows the relevant regulations and submit applications for ethical review to the “Biomedical Ethics Committee of Peking University” and the project ethical review lot number: IRB00001052-14010. The China Family Panel Studies were approved by the Ethical Committee of Peking University; informed consent was obtained from all individual participants; and the data were collected in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki. All methods were carried out in accordance with relevant guidelines and regulations or Declaration of Helsinki. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Aims: To investigate the associations between influencing factors with length of stay (LOS) and hospitalisation expenses in oral cancer (OC) patients, and to explore the potential pathways through which these factors influence hospitalisation expenses using path analysis., Design: Cross-sectional., Setting: A comprehensive tertiary hospital in southeastern China., Participants: A total of 810 patients with histologically confirmed primary OC admitted to the First Affiliated Hospital of Fujian Medical University, Fujian Province, between 2015 and 2020., Main Outcome Measures: LOS and hospitalisation expenses for OC patients., Results: The median hospitalisation expenses and LOS for OC patients in southeastern China were substantial, amounting to $6330 and 29 days, respectively. Treatment and surgery fees constituted the largest proportion of total expenses (28.59%), followed by inspection and laboratory test fees (20.63%), comprehensive medical service fees (19.27%), drug fees (18.09%) and medical consumables fees (11.69%). LOS was significantly associated with tumour site, surgery and chemotherapy. Factors such as longer LOS, poor oral hygiene, advanced tumour stage (II-IV), larger tumour size (>2 cm 3 ), surgery and bilateral neck dissection were strongly linked to higher hospitalisation expenses. Path analysis revealed that neck dissection had the highest total effect on hospitalisation expenses ( β =0.307), while surgery exerted an indirect effect on expenses via LOS ( β =0.021)., Conclusion: This study highlights the significant economic burden imposed by OC on patients and healthcare systems. While prevention and early diagnosis remain critical, our findings underscore several modifiable factors, including improving oral hygiene and optimising surgical protocols, such as chemotherapy and lymph node dissection, that present opportunities to reduce costs and enhance cost-effectiveness. These insights provide actionable targets for mitigating financial burdens and improving patient outcomes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

This study quantifies the impact of COVID-19 vaccination on hospitalization for COVID-19 infection in a South African private health insurance population. This retrospective cohort study is based on the analysis of demographic and claims records for 550,332 individuals belonging to two health insurance funds between 1 March 2020 and 31 December 2022. A Cox Proportional Hazards model was used to estimate the impact of vaccination (non-vaccinated, partly vaccinated, fully vaccinated) on COVID-19 hospitalization risk; and zero-inflated negative binomial models were used to estimate the impact of vaccination on hospital utilization and hospital expenditure for COVID-19 infection, with adjustments for age, sex, comorbidities and province of residence. In comparison to the non-vaccinated, the hospitalization rate for COVID-19 was 94.51% (aHR 0.06, 95%CI 0.06, 0.07) and 93.49% (aHR 0.07, 95%CI 0.06, 0.07) lower for the partly and fully vaccinated respectively; hospital utilization was 17.70% (95% CI 24.78%, 9.95%) and 20.04% (95% CI 28.26%, 10.88%) lower; the relative risk of zero hospital days was 4.34 (95% CI 4.02, 4.68) and 18.55 (95% CI 17.12, 20.11) higher; hospital expenditure was 32.83% (95% CI 41.06%, 23.44%) and 55.29% (95% CI 61.13%, 48.57%) lower; and the relative risk of zero hospital expenditure was 4.38 (95% CI 4.06, 4.73) and 18.61 (95% CI 17.18, 20.16) higher for the partly and fully vaccinated respectively. Taken together, findings indicate that all measures of hospitalization for COVID-19 infection were significantly lower in the partly or fully vaccinated in comparison to the non-vaccinated. The use of real-world data and an aggregated level of analysis resulted in the study having several limitations. While the overall results may not be generalizable to other populations, the findings add to the evidence based on the impact of COVID-19 vaccination during the period of the pandemic., Competing Interests: Geetesh Solanki is employed on a contractual basis by the South African Medical Research Council and NMG Consultants and Actuaries, an independent consulting firm providing consulting and actuarial services to South African private health insurance funds. NMG provided access to the data used for the study but did not have any other role or involvement in the study design, data collection and analysis, decision to publish, or preparation of the manuscript and Geetesh Solanki’s commercial affiliation to NMG therefore played no role in influencing the study. Geetesh Solanki’s association with NMG does not alter our adherence to PLOS One policies on sharing data and materials., (Copyright: © 2025 Solanki et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Each year, millions of people in low-and middle-income countries such as Nigeria are forced into poverty and financial ruin due to out-of-pocket (OOP) healthcare expenses. Our study assessed the prevalence and determinants of Catastrophic Healthcare Expenditure (CHE) experienced by households in Lagos, Nigeria., Methods: A descriptive community-based cross-sectional survey was conducted on 2492 households in Lagos from December 2022 to March 2023 in 4 Local Government Areas (LGAs) using a multistage sampling technique. Data was collected using pre-tested semi-structured questionnaires, and analysis was performed using STATA 15.0 software. Univariate, bivariate, and binary logistic regression analyses were conducted with statistical significance set at p<0.05, and a 95% Confidence Interval was calculated for the adjusted odds ratio (OR)., Results: The study revealed that 15% of households experience catastrophic health expenditure (CHE). Gender, marital status, educational level, occupation, personal income, health perception, household location, and health insurance enrollment were significantly associated with CHE. Additionally, gender, religion, income, household location, and self-rated health status were significant predictors of household CHE, with adjusted odds ratios of 4.42, 2.45, 1.00, 1.07, and 1.69, respectively., Conclusion: CHE is more prevalent among people with lower socio-economic status, urban residents, and those lacking health insurance. It is crucial to implement targeted initiatives to raise awareness about the benefits of health insurance and simplify the enrollment process for vulnerable groups, thereby alleviating the financial strain of healthcare expenses., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Wright et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: A lack of health insurance is a major barrier to the "health for all" agenda, where out-of-pocket (OOP) spending is the primary healthcare funding mechanism, a characteristic of Ethiopia's healthcare sector, leading it to plan to fully implement social health insurance (SHI) by 2014, but not yet, owing to significant opposition from public employees. The objective of this study was to look into the psychosocial determinants of the willingness to pay (WTP) for SHI among employees at a commercial bank in Dessie, Ethiopia., Methods: We employed a cross-sectional study (October to December 2023) design. A self-administered questionnaire was used to collect the data. We used SPSS 27 to analyze the data. The relationship between dependent and independent variables was determined using the odds ratios at a p value less than 0.05 with a 95% CI., Results: Of 396 samples, 264 (66.7%) responded, of which 93.9% had information about SHI, mainly from broadcast media (71.0%). More than three-fourths (75.8%) and two-thirds (64.4%), respectively, had poor knowledge and a negative perception regarding SHI. More than half (50.4%) of the participants were willing to pay, of which 88.5% (40.5% of the total participants) were interested in paying the 3.0% premium set by the government. The main reason for the WTP was to help those who could not afford medical costs, while the primary reason for not paying was the scheme's limited benefit packages. The WTP was found to be significantly affected by being female (AOR = 0.50, 95% CI: 0.26-0.98), being affiliated with orthodox Christianity (AOR = 0.48, 95% CI: 0.23-0.99), the presence of ≥5 family members in the household (AOR = 0.17, 95% CI: 0.06-0.52), experience of illness in the last 6 months (AOR = 4.95, 95% CI: 2.23-11.00), and perception toward it (AOR = 4.07, 95% CI: 2.03-8.17)., Conclusion: The WTP for the scheme was suboptimal, attributed to limited benefit packages, lack of medicines and equipment, and poor healthcare quality, and significantly influenced by being female, being affiliated with orthodox Christianity, family size, experience of illness in the last 6 months, as well as perceptions toward it., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Abate, Mekonen, Assfaw, Toleha and Bayked.)

Background: Breast cancer is a significant global health challenge, affecting millions annually and imposing a considerable burden on healthcare systems and economies worldwide. This cross-sectional study aims to determine the economic impact of breast cancer in Lorestan Province, western Iran., Methods: A retrospective cost-of-illness analysis utilizing a cross-sectional design was performed from November 2023 to July 2024. Data were collected using patient medical records and telephonic interviews. Costs were categorized into direct medical costs, direct non-medical costs, and indirect costs. A bottom-up approach was employed for cost calculation from a societal viewpoint, with a prevalence-based analysis., Results: The study analyzed 525 patients with an average age of 42.74 ± 11.75 years. The total economic burden of breast cancer was estimated at $5,394,409.13, with a mean of $10,275.07 per patient. Direct medical costs comprised 70.2% of the total expenses, primarily attributed to hospitalization, chemotherapy, and laboratory tests. Direct non-medical costs, including accommodation and transportation for patients and their companions, accounted for 12.5%. Indirect costs, largely stemming from productivity losses due to morbidity and mortality, represented 17.3% of the total burden., Conclusion: Breast cancer imposes a substantial economic burden on patients and their families in Lorestan Province. Enhancing health insurance coverage, providing government subsidies for treatment, and improving healthcare infrastructure to offer advanced diagnostic and treatment options locally are critical steps to alleviate this burden. Early detection and prevention programs can facilitate earlier diagnosis and reduce treatment costs. Comprehensive policies addressing both medical and non-medical expenses are necessary to improve patients' quality of life and lessen the financial challenges associated with breast cancer in Iran., Competing Interests: Declarations. Ethics approval and consent to participate: The ethics committee of the Lorestan University of Medical Sciences approved this study (approval code no. IR.LUMS.REC.1402.232). Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: This study aimed to determine the effects of primary care interventions on healthcare utilisation and estimated out-of-pocket (OOP) expenses in selected urban, rural and remote settings in the Philippines., Methodology: Context-specific measures relating to expanding healthcare provider networks, augmenting the health human workforce and subsidising transportation costs were implemented to strengthen primary care systems. In this study, two key outcomes were monitored: (1) monthly healthcare utilisation measured by the total number of outpatient consultations per site and (2) change in OOP expenses from baseline to endline within a 1 year study period., Results: All sites had a positive trend in monthly outpatient consultations in healthcare utilisation over 1 year. The remote site had the steepest increase in outpatient consultations, with a 401% increase compared with the baseline during the peak of consultations at month 7. The urban site had a 62% increase in outpatient consultations from baseline to month 6, while the rural site had a 251% increase from baseline to month 11, which corresponded to the peak month in terms of the number of outpatient consultations. The rural site had the largest decrease in estimated OOP expenses (50.3% reduction, 95% CI -88 to -13), followed by the remote site (33.2% reduction, 95% CI -67,+1) and the urban site (16.0% reduction, 95% CI -65,+33)., Conclusion: The rural site showed a significant reduction in estimated OOP expenses and an increase in healthcare utilisation. The remote site had the steepest increase in utilisation, but the reduction in estimated OOP expenses was not statistically significant. The urban site experienced the lowest increase in utilisation, and the smallest reduction in estimated OOP expenses, which was also not statistically significant. Implementing primary care benefits will necessitate contextualised approaches to avoid the inadvertent aggravation of inequities in healthcare., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Background: Transport by mobile stroke units (MSUs), which provide access to computed tomography scanning and intravenous blood pressure medications and thrombolytics, reduces time to treatment and may improve short-term functional outcomes for patients with acute stroke. The longer-term clinical and financial impacts remain incompletely understood. The aim of the study was to determine whether MSU care is associated with better health, utilization, and spending outcomes for patients with suspected acute stroke., Methods and Results: This was a retrospective, observational study of Medicare patients transported by MSUs versus traditional ambulances in New York City, from October 2016 to December 2019. The study included 167 Medicare patients with suspected acute stroke transported by MSU and 2518 propensity score-matched controls. Primary outcomes included length of stay and discharge destination at the index hospitalization, as well as risk of repeat hospitalization, number of emergency department visits, total costs of care, and death at 1 year. Of 167 patients (mean age, 79.9 years; 56.3% women) transported by an MSU for suspected acute stroke, 61.1% had an ischemic stroke/transient ischemic attack, 7.8% had an intracerebral hemorrhage, and 31.1% had a stroke mimic or other diagnosis. Compared with propensity score-matched control patients, MSU patients were significantly more likely to receive tissue-type plasminogen activator (49.9% versus 9.4%; difference, 37.5 percentage points [95% CI, 30.2-45.6]; P <0.001) but experienced similar lengths of stay (5.9 versus 6.7 days, P =0.13) and were similarly likely to be discharged to a skilled nursing facility (15.6% versus 15.1%, P =0.86). At 1 year, MSU patients had a mortality rate of 21.6%, and control patients had a mortality rate of 28.4%, although the difference did not reach statistical significance (difference, 6.8 percentage points [95% CI, -13.3 to 0.3]; P =0.058). They had similar rates of any repeat hospitalization (24% versus 23.2%, P =0.82) and emergency department visits without hospitalization (14% versus 12%, P =0.86), and there were no significant differences in total spending or specific types of spending., Conclusions: In this study of patients presenting with suspected acute stroke in New York City, transport by MSUs, compared with traditional ambulances, was associated with a trend toward a lower mortality rate at 1 year. Prospective trials and replication in other regions are warranted.

Background: Health literacy (HL) is crucial for effective healthcare utilization, but its relationship with private health insurance (PHI) enrollment and medical expenditure in South Korea remains unexplored., Objectives: This study aimed to examine the associations between HL, PHI enrollment, and annual out-of-pocket (OOP) medical expenditure in South Korea's universal healthcare system., Methods: Using data from the 2021 Korea Health Panel Study, we analyzed 5,469 participants aged 19-65. Logistic and multinomial logistic regression models were employed to assess factors influencing PHI enrollment. A Gamma GLM with a log- link function was used to examine the relationship between HL, PHI status, and OOP medical expenditure., Results: Among participants, 70.05% had indemnity insurance coverage, and 88.02% held at least one PHI policy. Individuals with sufficient HL showed higher indemnity insurance enrollment (71.47%) compared to those with inadequate HL (63.17%). In unadjusted analyses, those with sufficient HL were more likely to have indemnity insurance (OR = 1.46, 95% CI: 1.19-1.80) and PHI policies. However, after adjusting for sociodemographic and health-related factors, these associations became non-significant. Individuals with indemnity insurance spent 36% more on OOP medical expenditure compared to those without (p < 0.01), and OOP medical expenditure increased with the number of insurance policies (39.1%, 71.6%, and 107.5% higher for one, two, and three or more policies, respectively, all p < 0.01). Those with sufficient HL spent 18.9% less on OOP medical expenditure compared to those with inadequate HL (p < 0.01). However, after adjusting for other variables, the coefficients lost statistical significance. After adjusting for other variables, higher education levels were associated with lower OOP medical expenditure., Conclusions: While HL initially showed an association with PHI enrollment and reduced OOP medical expenditure, these relationships became non-significant after adjusting for socioeconomic and health-related factors. Higher education levels were associated with lower OOP medical expenditure, suggesting that educational attainment may better explain the observed HL effects. The positive association between PHI and OOP medical expenditure highlights the need for policy attention to ensure sustainable healthcare financing and appropriate medical service utilization in Korea's healthcare system., Competing Interests: Declarations. Ethics approval and consent to participate: This study analyzed publicly available secondary data from the Korea Health Panel. The analysis of such anonymized, publicly accessible data is exempted from Institutional Review Board review. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Revascularization therapies, such as percutaneous coronary intervention (PCI) and coronary artery bypass grafting (CABG), alleviate symptoms and treat myocardial ischemia. Patients with multivessel disease, particularly those undergoing 3-vessel PCI, are more susceptible to procedural complications, which can increase healthcare costs. Developing efficient strategies for resource allocation has become a paramount concern due to tightening healthcare budgets and the escalating costs of treating heart conditions. Therefore, it is essential to develop an evaluation model to estimate the costs of PCI surgeries and identify the key factors influencing these costs to enhance healthcare quality. This study utilized the National Health Insurance Research Database (NHIRD), encompassing data from multiple hospitals across Taiwan and covering up to 99% of the population. The study examined data from triple-vessel PCI patients treated between January 2015 and December 2017. Additionally, six machine-learning algorithms and five cross-validation techniques were employed to identify key features and construct the evaluation model. The machine learning algorithms used included linear regression (LR), random forest (RF), support vector regression (SVR), generalized linear model boost (GLMBoost), Bayesian generalized linear model (BayesGLM), and extreme gradient boosting (eXGB). Among these, the eXGB model exhibited outstanding performance, with the following metrics: MSE (0.02419), RMSE (0.15552), and MAPE (0.00755). We found that the patient's medication use in the previous year is also crucial in determining subsequent surgical costs. Additionally, 25 significant features influencing surgical expenses were identified. The top variables included 1-year medical expenditure before PCI surgery (hospitalization and outpatient costs), average blood transfusion volume, ventilator use duration, Charlson Comorbidity Index scores, emergency department visits, and patient age. This research is crucial for estimating potential expenses linked to complications from the procedure, directing the allocation of resources in the future, and acting as an important resource for crafting medical management policies., Competing Interests: Declarations. Ethics approval and consent to participate: Following national regulations and with the approval of the Institutional Review Board (IRB) at Fu Jen Catholic University, the requirement for obtaining informed consent was waived for this study. The waiver was granted based on the assurance that participant information would remain confidential, with data anonymized through unique identifiers (protocol code C108121; approved on March 5, 2020). This waiver was deemed appropriate as the study met specific criteria outlined in Taiwan’s Human Subjects Protection Act and rigorously adhered to all established protocols. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: Since their establishment, the two predominant social health insurance schemes in China, Urban Employee Medical Insurance (UEMIS) and Urban and Rural Residents' Medical Insurance (URRMS), have primarily focused on covering non-inpatient expenditure, while costs associated with outpatient care and pharmaceutical purchases have been largely excluded from the insurance benefit package. This study intends to analyze the distribution of non-hospitalization expenditure and assess resulting financial risks, with an objective to reform the health insurance benefit package by including coverage for non-hospitalization costs., Methods: The primary data were obtained from the 2018 wave of CHARLS, encompassing a total of 12942 individuals for analysis. Assess the financial risk associated with non-hospitalization expenses through catastrophic health expenditures (CHE) and examine the determinants of CHE using logistic regression analysis., Results: Over 60% of the participants availed non-inpatient services in the month preceding the investigation. A smaller proportion (14.26 and 14.28% for UEMIS and URRMS enrollee, respectively) utilized outpatient services provided by medical institutions, while a larger proportion (54.20 and 56.91% for UEMIS and URRMS enrollee, respectively) purchased medication from pharmacies. The study reveals a distinct subgroup of participants (8.91 and 6.82% for UEMIS and URRMS enrollee, respectively) who incurs substantial out-of-pocket non-inpatient expenditure, surpassing 1,000 RMB per month. However, reimbursement for non-inpatient expenditures is significantly limited under the two predominant health insurance schemes, and there is minimal disparity in the distribution of non-inpatient expenses before and after insurance reimbursement. The prevalence of CHE resulting from non-inpatient costs was substantial, particularly among participants enrolled in URRMS (25.06%) compared to those enrolled in UEMIS (14.26%). The presence of chronic diseases, advanced age, and limited financial resources are all determinants contributing to the occurrence of CHE., Conclusion: The incorporation of non-inpatient expenses into China's fundamental health insurance plan remains a contentious issue, given the limited available evidence. This study presents empirical evidence underscoring the significance of non-inpatient expenditures as a determinant of financial risk, thereby emphasizing the imperative to adjust China's fundamental health insurance benefit package in order to address risks associated with non-inpatient costs, particularly among individuals with chronic illnesses and limited income., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Zhang and Zhu.)

This paper proposes a multidimensional vulnerability index for a setting of protracted conflict, which is applied to study the relationship between financial vulnerability and catastrophic healthcare expenditure (CHE) incidence in the Occupied Palestinian Territory in 2018. We find that our index better captures the extent of financial risk protection in health compared to conventional measures of financial welfare. Results indicate that the most vulnerable groups experience a significantly higher likelihood of incurring CHE, and this likelihood is increased for those living in the West Bank compared to the Gaza Strip. We also find a lack of protection from existing health insurance types against the risk of CHE. Our analysis provides valuable insights about key aspects, such as health financing and insurance bottlenecks, that will deserve careful policy attention in efforts to rebuild the Palestinian health system, following the Israel-Hamas war., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Hatamyar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: Little is known about the role that charitable copay assistance (CPA) plays in addressing access to care and financial distress. The study sought to evaluate financial distress and experience with CPA among patients with cancer and autoimmune disease., Methods: This is a national cross-sectional self-administered anonymous electronic survey conducted among recipients of CPA to cover the costs of a drug for cancer or autoimmune disease. Self-reported financial distress as measured by Comprehensive Score for Financial Toxicity as well as health care spending and experience with financial barriers to care were evaluated, as were perspectives on policy questions related to CPA and costs of care., Results: Among 1566 respondents (1108 with cancer and 458 with autoimmune disease, median age 71, 51% female, 89% White, 69% household income <$60,000), 53% reported mild and 31% moderate/severe financial distress, despite CPA. Eighteen percent reported missing recommended care because of costs. Most respondents (96%) had Medicare, 55% reported supplemental insurance, and 66% believed that insurance would prevent them from facing high costs of health care. A total of 52% reported paying more than $100 monthly in drug costs and 41% spending more than 10% of monthly income on health care. Financial distress was similar among patients with cancer and autoimmune diseases. In multivariable regression analysis, younger age, less education, unemployment, higher comorbidity, and lower income were independently associated with higher financial distress., Conclusions: This study informs policy debate over the role of CPA foundations in the U.S. health insurance safety net and highlights the inadequacy of Medicare to guarantee access to care for older patients with chronic illness., (© 2025 American Cancer Society.)

Background: Many studies have shown that using new technologies and medical equipment contributes to increasing health expenditure. Relatively less empirical studies have measured the impact of medical equipment on rising medical costs in China. Against this backdrop, we aim to examine whether the large-scale medical equipment deployment explains the increase in health expenditure., Methods: Quasi-experimental research design with a difference-in-differences approach was adopted to explore whether an increase in the number of large-scale medical equipment impacts on outpatient and inpatient costs. Data were obtained from the 2011-2017 Health Financial Annals in Shaanxi province, China., Results: The increase in the number of large-scale medical equipment by 1 - regardless of the initial configuration - resulted in the increase of the average cost per outpatient visit and the average cost per inpatient visit by 10.6% (p < 0.05) and 8.0% (p < 0.05), respectively. Our complex difference in differences model illustrates that the increase in the number of large-scale medical equipment by 1 - regardless of the initial configuration-results in an increase in the average diagnostic cost per outpatient visit and the average diagnostic cost per inpatient visit by 27. 3% (p < 0.01) and 25. 5% (p < 0.01), respectively., Conclusions: Our findings show that the medical expenditure differs significantly with the increase in the number of large-scale medical equipment. This study mainly revealed the relationship between the growth of the number of large-scale medical equipment and medical expenditure. Our novel perspective was used to measure the phenomenon of excessive use, and to explain the social phenomenon of inaccessible and expensive medical care in China., Competing Interests: Declarations. Ethics approval and consent to participate: The data used in this submission did not collect from human subjects. The data only includes information about healthcare institutions and were collected from Health Financial Annals of Shaanxi province. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: In low and middle-income countries like Ghana, out-of-pocket (OOP) payments remain a significant barrier to healthcare access, often leading to catastrophic health expenditures (CHE). This study evaluates the incidence of CHE among patients treated for long bone fractures at Ghana's major teaching hospitals, providing insight into the economic burdens faced by these patients., Methods: This cross-sectional study analyzed data from 2,980 patients with long bone fractures treated at four major teaching hospitals in Ghana from July 2017 to July 2020. We collected demographic, clinical, and economic data, including OOP payments and patient-reported income, to assess the incidence of CHE at varying income thresholds (10%, 20%, 30%, 40%). Logistic regression models were used to identify predictors of CHE, with variables including age, gender, education, region, fracture type, injury severity, and NHIS coverage., Results: The incidence of CHE was highest at the 10% income threshold (53.21%) and decreased with higher thresholds. Male patients incurred higher average OOP payments ($343.68) than females ($271.63), and patients with tibia fractures faced the highest financial burden. Educational and regional disparities were evident, with lower CHE rates among patients with higher educational attainment and those from northern regions. NHIS coverage provided limited financial relief, particularly at lower income thresholds., Conclusion: Long bone fractures impose a substantial financial burden on patients in Ghana, with significant gender, educational, and regional disparities in OOP payments and CHE. While NHIS provides some relief, it remains inadequate in protecting patients from financial distress. Policy interventions aimed at expanding NHIS coverage, reducing OOP payments for high-cost treatments, and addressing geographic inequities are urgently needed to improve financial protection for patients with long bone fractures in Ghana. Future research should focus on capturing long-term financial impacts and improving income data accuracy to better inform healthcare policies., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical clearance to conduct the study was obtained from the Committee on Human Research Publications and Ethics (CHRPE) of Kwame Nkrumah University of Science and Technology (Approval number: CHRPE/AP/290/19). The study was conducted in full compliance with the ethical principles outlined in the Declaration of Helsinki and adhered to all applicable national guidelines. Informed consent was obtained from all participants prior to their inclusion in the study. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Objectives: To identify, measure and value the economic burden of musculoskeletal (MSK) disorders in the Kilimanjaro region, Tanzania., Design: Community-based cross-sectional survey (undertaken between January and September 2021)., Setting: Hai district, Kilimanjaro, Tanzania., Participants: Households resident in the Hai district., Methods: A two-stage cluster sampling was used to select a representative sample of all Hai district residents. Clinical screening tools were used to identify and measure MSK disorders through a tiered approach. An economic questionnaire measuring healthcare costs, out-of-pocket costs, absenteeism, presenteeism and work productivity loss was administered to those with likely MSK disorders and selected controls (individuals without MSK disorders, matched by age and gender). Resource use was valued using country-specific costs. Two-part model regressions were fitted. A descriptive analysis of catastrophic expenditure was also conducted., Main Outcome Measure: Healthcare costs, productivity costs and total costs., Results: Annual average productivity and healthcare costs were, respectively, 3.5 and 3 times higher for those with likely MSK disorders than controls. Productivity costs of individuals with MSK disorders were Int$487 vs Int$132 in the control group (difference: Int$355, 95% CI Int$222 to Int$488). Healthcare costs in those with MSK were Int$269 vs Int$88 in the control group (difference: Int$181, 95% CI Int$34 to Int$327). The difference in terms of out-of-pocket expenses was economically substantial in magnitude, although not statistically significant., Conclusion: The evidence will be used to inform policies addressing MSK disorders, by promoting the design of interventions, service provision, health promotion and awareness activities at local, regional and national level., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. Re-use permitted under CC BY. Published by BMJ Group.)

Background: Multimorbidity is associated with significant out-of-pocket expenditures (OOPE) and catastrophic health expenditure (CHE), especially in low- and middle-income countries like India. Despite this, there is limited research on the financial burden of multimorbidity in outpatient and inpatient care, and cross-state comparisons of CHE are underexplored., Methods: We conducted a cross-sectional analysis using nationally representative data from the National Sample Survey 75th Round 'Social Consumption in India: Health (2017-18)', focusing on patients aged 30 and above in outpatient and inpatient care in India. We assessed multimorbidity prevalence, OOPE, CHE incidence, and CHE intensity. Statistical models, including linear, log-linear, and logistic regressions, were used to examine the financial risk, with a focus on non-communicable diseases (NCDs), healthcare facility choice, and socioeconomic status and Epidemiological Transition Levels (ETLs)., Results: Multimorbidity prevalence in outpatient care (6.1%) was six times higher than in inpatient care (1.1%). It was most prevalent among older adults, higher MPCE quintiles, urban patients, and those with NCDs. Multimorbidity was associated with higher OOPE, particularly in the rich quintile, patients seeking care from private providers, low ETL states, and rural areas. CHE incidence was highest in low ETL states, private healthcare users, poorest quintile, males, and patients aged 70 + years. CHE intensity, measured by mean positive overshoot, was greatest among the poorest quintile, low ETL states, rural, and male patients. Log-linear and logistic regressions indicated that multimorbidity patients with NCDs, those seeking private care, and those in low ETL states had higher OOPE and CHE risk. The poorest rural multimorbidity patients had the greatest likelihood of experiencing CHE. Furthermore, CHE intensity was significantly elevated among multimorbidity patients with NCDs (95% CI: 19.29-45.79), patients seeking care in private, poorest, and from low ETL states (95% CI: 7.36-35.79)., Conclusions: The high financial burden of OOPE and CHE among multimorbidity patients, particularly those with NCDs, highlight the urgent need for comprehensive health policies that address financial risk at the primary care level. To alleviate the financial burden among multimorbidity patients, especially in low-resource settings, it is crucial to expand public healthcare coverage, incorporate outpatient care into financial protection schemes, advocate for integrated care models and preventive strategies, establish standardized treatment protocols for reducing unnecessary medications linked to polypharmacy, and leverage the support of digital health technologies., Competing Interests: Declarations. Ethics approval and consent to participate: Ethical approval was not required for this study as it used only anonymized data from secondary sources, publicly available from the National Sample Survey Office (NSSO). Therefore, no ethical issues or approval from an ethics committee, nor consent to participate, were necessary. All methods were conducted in accordance with relevant guidelines and regulations. Consent for publication: Not applicable. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Background: This study aimed to investigate and analyze the current status of oral disease treatment among the older adult in Guangxi Zhuang Autonomous Region, while also assessing the continuing medical education (CME) needs of dental institution personnel regarding oral diseases in this population., Methods: Convenience sampling was used to investigate the oral disease treatment among older adults and to assess CME needs of dental institution personnel regarding oral diseases in this population across various oral medical and health institutions in Guangxi., Results: A total of 754 valid questionnaires were collected, of which 70.3% were from non-public oral health institutions. Out-of-pocket costs for older adults were as high as 91.3%. The per capita cost of older adult patients was beyond 500 yuan in 51.6% of the oral health institutions. In terms of CME training, 32.8% of dental institution medical personnel have participated in CME courses specifically on oral diseases in the older adult. Meanwhile, 69.9% of institutions have expressed a need for CME training on oral diseases in the older adult., Conclusion: Non-public oral health institutions account for a significant proportion, and the older adult primarily pay out-of-pocket for oral disease treatment in these facilities. The high cost of treatment may pose a significant barrier to the older adult seeking oral healthcare. Increasing CME programs targeted at geriatric oral diseases can help enhance the treatment capabilities of dental healthcare workers and improve oral health outcomes for the older adult population., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Li, Huang, Pan, Tao, Pan, Pan, He, Wang and Huang.)

Background: Upazila Health Complexes (UzHC) serve as the backbone of primary healthcare (PHC) at the sub-district level in Bangladesh, delivering comprehensive healthcare services including both inpatient and outpatient services to the grassroots levels. However, not all the prescribed medicines and diagnostics services are always available at these facilities for outpatient care. This results in out-of-pocket expenditure (OOPE) to the patients for getting prescribed medicines and diagnostics services which has not been properly explored. Thus, we aimed to estimate the overall provider and user costs for outpatient care services at selected UzHCs in Bangladesh., Methods: An ingredient-based costing approach was applied to estimate the costs for the most commonly reported illnesses at outpatient of UzHCs from a societal perspective. We conducted a health facility survey at four purposively selected UzHCs to estimate provider costs and a patient exit survey among 452 patients of selected illnesses to estimate the user costs. Commonly reported illnesses were identified in consultation with healthcare providers of these facilities. The difference between costs of prescribed and provided medicines at UzHCs was estimated using the market prices. Data was collected between February to March 2021., Results: The societal costs of the common outpatient illness or symptoms varied significantly, ranging from BDT 642 to BDT 1,384 per episode. Antenatal care had the highest cost burden at BDT 1,384, followed by respiratory illness at BDT 783 and urinary tract infection at BDT 670. On average, the provider spent BDT 289 for treating an outpatient, while a patient incurred BDT 446 as OOPE. Further, a patient was expected to spend an average of BDT 341 for purchasing medicines not provided from UzHCs., Conclusion: Our study found significant gaps between prescribed and provided medicines at UzHCs, leading to higher OOPE for patients. The current healthcare resource allocation strategy does not consider the outpatient load and healthcare demand at PHC facilities, which further exacerbates this gap. Addressing this gap requires a fundamental shift towards a demand-driven resource allocation model within the healthcare financing strategy to improve healthcare access and achieve health for all., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2025 Hasan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

This study aimed to analyze the impact of poor oral function on medical expenditures among older adults. We diagnosed oral hypofunction based on dental data obtained from oral health examinations and examined its association with several annual medical expenditures. Compared to individuals without oral hypofunction, those with oral hypofunction incurred higher total, outpatient medical, inpatient medical, dental, dispensing medical, and lifestyle-related medical expenditures. Those with high medical expenditure costs were significantly more likely than those without to be 80 years old, male, with oral hypofunction, poor oral hygiene, xerostomia, poor lip closure, physical frailty, mental frailty, and subjective poor health. Logistic regression analysis indicated that oral hypofunction was significantly associated with total medical, inpatient medical, dental outpatient, dispensing medical, and lifestyle-related medical expenditures, compared to those without oral hypofunction (p < 0.05). Additionally, every increase in the number of items with declined oral function and total medical, dental, and dispensing medical expenditures increased significantly (p < 0.01). The results of this study suggest an association between oral hypofunction and several medical expenditures. The prevention and early detection of oral hypofunction would reduce not only dental but also medical expenditures by the maintenance of good health., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Purpose: The Oncology Care Model (OCM), a value-based payment model for traditional Medicare beneficiaries with cancer, yielded total spending reductions that were outweighed by incentive payments, resulting in net losses to the Centers for Medicare & Medicaid Services. We studied whether the OCM yielded spillover effects in total episode spending, utilization, and quality among commercially insured and Medicare Advantage (MA) members, who were not targeted by the program., Patients and Methods: This observational study used administrative claims from a large national payer, yielding 157,189 total patients with commercial insurance or MA with solid malignancies who initiated 229,376 systemic anticancer therapy episodes before (2012-2015) and during (2016-2021) the OCM at 125 OCM-participating practices (a subset of total OCM practices) and a 1:10 propensity-matched set of 860 non-OCM practices. We used difference-in-differences analyses to assess the association between the OCM and total episode spending, defined as medical spending during a 6-month episode. Secondary outcomes included hospitalization and emergency department (ED) utilization and quality measures., Results: From the pre-OCM to the OCM period, mean total episode payments increased from $45,504 in US dollars (USD) to $46,239 USD for OCM-participating practices, and increased from $50,519 USD to $58,591 USD for non-OCM practices (adjusted difference-in-differences -$6,287 USD [95% CI, -$10,076 USD to -$2,498 USD], P = .001). The OCM was associated with adjusted spending decreases for both high-risk (-$6,756 USD [95% CI, -$10,731 USD to -$2,781 USD], P = .001) and low-risk (-$4,171 USD [95% CI, -$7,799 USD to -$543 USD], P = .025) episodes. OCM-associated spending reductions were strongest for outpatient (-$5,243 USD [95% CI, -$8,589 USD to -$1,897 USD], P = .002) and infused/injected anticancer drug (-$3,031 USD [95% CI, -$5,193 USD to -$869 USD], P = .006) spending. There were no associations between OCM participation and changes in hospital or ED utilization nor quality of care., Conclusion: The OCM was associated with reductions in spending for nontargeted members, a spillover effect.

Purpose: To evaluate cancer patients' willingness to pay for exercise services and oncology health professionals' perception of patients' willingness to pay., Methods: A mixed-methods design was used. Online questionnaires and semi-structured interviews were administered to people with any type of cancer and oncology health professionals delivering clinical care. Questionnaires assessed patients' willingness to pay for one consultation with a cancer-trained exercise specialist (i.e. exercise physiologist/physiotherapist) and regular group exercise sessions supervised by cancer-trained exercise specialists. Interviews probed factors associated with the out-of-pocket cost of adopting exercise guidelines. Data were analysed using standard descriptive statistics and an interpretive descriptive approach to qualitative analysis., Results: Participants included 450 cancer patients and 300 oncology health professionals. A randomly selected sub-set of 30 patients and 31 health professionals completed interviews. The majority of patients surveyed would pay for an exercise consultation (94%) and regular group exercise sessions (58.4% extremely likely; 24.7% moderately likely; standard 7-point Likert scale response options). A greater proportion of patients who were employed (97.2% p = 0.030), below average general health (97.0% p = 0.031), were female (96.1% p = 0.013), and insufficiently active (95.3% p = 0.048) were willing to pay for exercise services. Oncology health professionals perceived fewer patients would be willing to pay for exercise services (p < 0.001; consultation = 7.0% extremely likely, 32.7% moderately likely; regular supervised sessions = 5.3% extremely likely; 32.0% moderately likely)., Conclusions: When briefly informed of the benefits and costs of exercise, the majority of patients in this study would pay for cancer-specific exercise services. There is an opportunity to align perceptions of willingness to pay among patients and health professionals involved in their care to help facilitate the uptake of exercise guidelines., Competing Interests: Declarations. Ethics approval: This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by Peter MacCallum Cancer Centre Human Research Ethics Committee (HREC/74874). Consent to participate: Informed consent was obtained from all individual participants included in the study. Competing interests: PC is the recipient of a Victorian Government Mid-Career Research Fellowship through the Victorian Cancer Agency. PC is the Founder and Director of EX-MED Cancer Ltd, a not-for-profit organization that provides exercise medicine services to people with cancer. PC is the Director of Exercise Oncology EDU Pty Ltd, a company that provides fee for service training courses to upskill exercise professionals in delivering exercise to people with cancer. AB, CD, BP, PM, MC and MK have no competing interests to declare that are relevant to the content of this article., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

This document determines the causes of mortality (2008-2022) and calculate per capita health expenditure (2013-2021) in octogenarians, nonagenarians and centenarians in the Colombian population, considering year, gender and age group. For this nationwide retrospective descriptive observational study, epidemiological regions, urban/rural areas and morbidities were also studied. A mean of 75,552 deaths was observed from 2008 to 2022. Deaths were higher due to ischemic heart disease, COVID-19, chronic obstructive pulmonary disease, cancer, and cerebrovascular diseases in the oldest old Colombian population with urban areas having higher mortality rates than rural areas (an average of 948 (min: 847, max: 1207) against 630 (min: 558, max: 789) per 10,000 people, respectively). Conditions of cerebrovascular diseases, cancer, influenza pneumonia and chronic obstructive pulmonary disease were the most expensive in health care, summing above 5000 purchasing power parity USD on average (min: 2234, max: 7539). These conditions, along with hypertension and diabetes mellitus, were the most frequently recorded. COVID-19 incurred higher health expenditure in rural areas compared to urban areas (1090 vs. 519 purchasing power parity USD respectively). High prevalence (14·3%) and medical attention (16·8 health care utilisations per capita) were shown for organic mental disorders. Our analysis found that centenarians survived COVID-19 more than octogenarians and nonagenarians, with several hypotheses attributing this to their immune profiles. We found high expenditure on HIV/AIDS among older males suggesting the need for further study on sexually transmitted diseases prevention in this population. Lastly, Alzheimer's disease, particularly in rural areas, had substantial expenditure. Therefore, neurodegenerative diseases and the impact of stressful events on mental health must be priorities for the health system to ensure adequate resource management., Competing Interests: Declarations. Competing interests: The authors declare no competing interests., (© 2025. The Author(s).)

Introduction: This article explores the impact of innovation on urban public health, with a particular focus on panel data from 15 sub-provincial cities in China. The study aims to provide scientific evidence for policymakers by analyzing how technological innovation affects urban public health levels., Methods: The study used a panel model for empirical analysis which based on panel data from 15 sub provincial cities across the country, using the number of doctors per 10,000 people and per capita financial medical and health expenditure as proxy variables for urban public health, and using the level of technological development as the core explanatory variable for regression analysis., Results: The research results show that: (1) for public health quantified by the number of doctors per 10,000 people in cities, innovation does not have a significant promoting effect on urban public health; (2) Compared to the number of doctors per 10,000 people in a region, the per capita financial expenditure on healthcare can better measure the level of urban public health; (3) Innovation has a significant impact on urban public health, measured by per capita fiscal expenditure on healthcare., Discussion: In order to transform technological innovation into a driving force for the development of urban public health, efforts must be made from multiple aspects. Currently, building a strong foundation for people's health relies on the support of science and technology, and enhancing innovation as a primary driving force is crucial. China urgently needs to improve the stability and competitiveness of its pharmaceutical industry and supply chain, break through key core technologies, and take the initiative in the future development of the pharmaceutical industry., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Zhao, Li and Qian.)

Background: This study delves into the determinants of alcohol consumption and expenditure in Ecuador, focusing on personal characteristics, education levels, and regional variations. This study aimed to provide nuanced insights into alcohol-related behaviors within the Ecuadorian population., Methods: Employing probit and Tobit models, the study ensures a robust analytical framework to assess the factors influencing alcohol consumption and expenditure. Data were collected from the 2014 Survey of Living Conditions, spanning urban and rural areas of Ecuador, guaranteeing a diverse population representation. The study includes individuals from random households, totaling 66,418 individuals over 18 years. Employing various measurements, including the use of a probit model for alcohol consumption and a Tobit model for alcohol expenditure, the study considers key variables such as smoking, gender, age, employment status, and regional location, contributing to a detailed understanding of alcohol-related behaviors., Results: For female individuals, there is a negative association, decreasing the probability of alcohol consumption by 6.6% ( p -value: 0.000). Conversely, being a smoker exhibits a positive association, increasing the likelihood by 10.2% ( p -value: 0.000). Regarding alcohol expenditure, being female is linked to a reduction in spending by $0.885 ( p -value: 0.000). Being a smoker reveals an increase in spending by $0.914 ( p -value: 0.000). Regional variations, education level, and employment status play crucial roles in shaping alcohol-related behaviors., Conclusion: This research provides nuanced insights into the socioeconomic determinants of alcohol-related behaviors in Ecuador. The findings underscore the necessity for targeted public policies, including gender-specific interventions, anti-smoking strategies, and considerations for regional variations., Competing Interests: The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2025 Yajamín-Villamarín.)