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Introduction: As the Chinese government places an increasing emphasis on public fitness services, there has been a concomitant growth in public demand for greater fiscal expenditure in this area. However, in light of the constrained growth in government financial resources, it is of paramount importance to allocate these resources in a rational manner in order to effectively address the public's fitness and health needs. This study aims to evaluate the efficiency of public expenditure on national fitness services across China, thereby providing valuable insights for policymakers to optimize resource allocation and improve service efficiency., Methods: The study employs a super-efficiency Data Envelopment Analysis (DEA) model, in conjunction with the Malmquist Index and Tobit regression model, to assess the efficiency of fiscal spending on fitness services in 31 Chinese provinces from 2017 to 2020. The analysis employs both static and dynamic approaches to present an objective view of the development of public fitness service levels across different regions and to empirically identify the key factors influencing fiscal spending efficiency., Results: The findings indicate substantial regional variations in the efficiency of fiscal expenditure on public fitness services. While some provinces demonstrate high efficiency in the use of public funds, others exhibit notable inefficiencies, particularly in areas with lower levels of economic development and population density. The findings underscore the existence of redundant expenditure and the varying effectiveness of resource utilization across provinces., Discussion: The study recommends that future strategies prioritize the scientific planning of fiscal inputs into public fitness services, the precise optimization of expenditure structures, the exploration of collaborative supply mechanisms, the expansion of demand-driven feedback channels, the integration of technological innovations, and the acceleration of digitalization in public fitness services., 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 © 2024 Gao, Cao and Gu.)

Introduction: Healthcare financing systems, dependent on out-of-pocket expenditure(OOPE), impose a heavy burden on those who use the services regularly, such as patients suffering from chronic diseases. High OOPE for health services leads to decreased utilization of the services and/or catastrophic health expenditure, which would significantly impede the achievement of Universal Health coverage., Objective: We aimed to determine variations in OOPE and factors associated with Catastrophic Health Expenditure (CHE) of households with patients suffering from non-communicable diseases(NCDs) in four districts., Methods: A survey was conducted among 2344 adult patients having selected NCD/s. Multi-stage stratified cluster sampling selected respondents from 4 districts representing urban, rural, semi-urban, and estate. Data was collected using a validated interviewer-administered questionnaire. Logistic regression identified the predictors of CHE(> 40%). Significance was considered as 0.05., Results: Common NCDs were hypertension(29.1%), diabetes(26.8.0%), hyperlipidaemia(9.8%) and asthma(8.2%). Only 13% reported complications associated with NCDs. Fifty-six percent(N = 1304) were on regular clinic follow-up, and majority utilized western-medical government hospitals(N = 916,70.2%). There were 252 hospital admissions for chronic-disease management in the past 12 months. Majority(86%) were admitted to government sector hospitals. Most patients incurred nearly SLR 3000 per clinic visit and SLR 3300 per hospital admission. CHE was beyond 40% for 13.5% of the hospital admissions and 6.1% of the regular clinic follow-up. Patients admitted to private sector hospitals had 2.61 times higher CHE than those admitted to government sector hospitals., Conclusions: Patients with NCDs incurred high OOPE and faced CHE during healthcare seeking in Sri Lanka. The prevalence of NCDs and complications were high among the participants. Patients with chronic conditions incur high OOPE for a single clinic visit and a hospital admission. Patients incur high OOPE on direct medical costs, and district-wise variations were observed. The proportion with more than 40% CHE on monthly clinic care was high. Patients being followed up in the government sector are more likely to have CHE when obtaining healthcare and are more likely to face barriers in obtaining needed health services. The services rendered to patients with chronic conditions warrant a more integrative approach to reduce the burden of costs and related complications., (© 2024. The Author(s).)

Objective: To explore the direct economic burden and factors affecting out-of-pocket direct costs of multidrug-/rifampicin-resistant pulmonary tuberculosis (MDR/RR-PTB) patients in Jiangsu Province. Methods: MDR/RR-PTB patients diagnosed and treated at 13 municipal tuberculosis (TB)-designated hospitals in Jiangsu Province between January 1, 2021, and December 31, 2022, were included, and basic information and direct economic costs were obtained through questionnaires and hospital information systems. Stepwise multiple linear regression was used to analyze the factors influencing patients' out-of-pocket direct costs. Results: The age of the 233 MDR/RR-PTB patients was (44.04±15.64) years. The M ( Q 1 , Q 3 ) direct medical expense of the patients was 134 051.00 (98 934.01,163 205.73) Yuan, of which the M ( Q 1 , Q 3 ) reimbursement by health insurance or policy reduction was 100 462.10 (78 120.00,130 816.00) Yuan, and the M ( Q 1 , Q 3 ) out-of-pocket direct medical expense was 21 694.62 (14 734.83,37 813.00) Yuan. The M ( Q 1 , Q 3 ) direct non-medical expense was 4 971.00 (3 138.00,7 870.00) Yuan. Age, registered residence location, TB resulting in divorce or separation from spouse or partner, drug resistance test results, and treatment regimens were the influencing factors associated with out-of-pocket direct costs for MDR/RR-PTB patients. Conclusions: The direct economic burden caused by MDR/RR-PTB in Jiangsu Province is heavy. It is necessary to emphasize psychological guidance and care for MDR/RR-PTB patients, improve the diagnosis, treatment, and management of MDR/RR-PTB, and effectively reduce the economic burden of MDR/RR-PTB patients.

Importance: Approximately 30% of US families with employer-sponsored health insurance, disproportionately drawn from high-income groups, benefit from flexible spending accounts (FSAs) or health savings accounts (HSAs). The combined association through both out-of-pocket spending and premiums of these tax-favored accounts with health care expenditures and tax expenditures remain uncertain., Objective: To compare the health care and health-related tax expenditures among families holding FSAs, HSAs, or neither type of account., Design, Setting, and Participants: This cross-sectional study used family-level data from the Medical Expenditure Panel Survey from January 1, 2011, to December 31, 2019, and conducted regression models, controlling for demographic and socioeconomic characteristics, chronic conditions, prior health care expenditures, and marginal tax rates to analyze how holding tax-favored accounts is associated with families' health care spending and tax expenditures. The sample was restricted to families included in the survey for 2 years, with no members 65 years or older, and with at least 1 policyholder covered (only) by full-year employer-sponsored insurance. Data were analyzed from December 1, 2023, to April 30, 2024., Exposures: Holding FSAs or HSAs., Main Outcomes and Measures: Out-of-pocket and insurance-paid health expenditures overall and by service were measured. Health-related tax expenditures were based on tax-excluded insurance premiums and tax-sheltered out-of-pocket expenses., Results: Of the 17 038 families included in the study sample, 2628 held FSAs (weighted 17%) and 1845 (weighted 13%) held HSAs. In regression-adjusted models, families with FSAs spent a mean of 20% or $2033 (95% CI, $789-$3276) more on health care annually than non-account holding families, largely due to increased insurer-paid expenses. Families with HSAs spent a mean of 44% or $697 (95% CI, $521-$873) more on out-of-pocket expenditures and had insignificantly higher insurance-paid expenditures than families without accounts, resulting in overall expenditures comparable to those of non-account holders. The additional tax expenditures associated with FSAs were a mean of $1306 (95% CI, $536-$2076) annually per family. Both types of funds were associated with significant increases in tax expenditures from additional office-based visits ($445 [95% CI, $244-$645] for FSAs and $174 [95% CI, $11-$336] for HSAs), outpatient visits ($330 [95% CI, $132-$528] for FSAs and $250 [95% CI, $15-$485] for HSAs), dental visits ($180 [95% CI, $126-$233] for FSAs and $165 [95% CI, $104-$226] for HSAs), and vision care ($36 [95% CI, $28-$45] for FSAs and $52 [95% CI, $40-$64] for HSAs)., Conclusions and Relevance: Participation in FSAs is associated with higher health care expenditures and tax expenditures, while HSAs are not associated with reduced expenditures. Tax policy could be better targeted to enhance insurance coverage and health care accessibility.

We estimate the efficiency of health spending in 145 middle and high-income and the potential gains from improving efficiency for a range of health system outputs using Robust Data Envelopment Analysis for 2010-2014 and 2015-2019 and examine associations with health system characteristics. Focusing on Latin American and Caribbean countries, we find large variability in efficiency and overall substantial potential gains in the later period, despite improvements over time. Our results suggest that, for example, improving spending efficiency could increase life expectancy at birth by 3.5 years (4.6%), or slightly more than the 3.4-year improvement in average life expectancy in the region between 2000 and 2015. Similarly, improved efficiency could reduce neonatal mortality by 6.7 per 1,000 live births (62%), increase service coverage by 6 percentage points (8.7%), and reduce the rich-poor gap in birth attendance by 10 percentage points (12.6%). We find that governance quality is positively associated with efficiency. Overall, the findings indicate an urgent need to improve efficiency in the region and substantial scope for realizing the potential gains of such improvements., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2024 Goyeneche, Bauhoff. 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: Non-communicable diseases (NCDs) predispose households to exorbitant healthcare expenditures in health systems where there is no access to effective financial protection for healthcare. This study assessed the economic burden associated with the rising burden of type-2 diabetes (T2D) and hypertension comorbidity management, and its implications for healthcare seeking in urban Accra., Methods: A convergent parallel mixed-methods study design was used. Quantitative sociodemographic and cost data were collected through survey from a random community-based sample of 120 adults aged 25 years and older and living with comorbid T2D and hypertension in Ga Mashie, Accra, Ghana in November and December 2022. The monthly economic cost of T2D and hypertension comorbidity care was estimated using a descriptive cost-of-illness analysis technique from the perspective of patients. Thirteen focus group discussions (FGDs) were conducted among community members with and without comorbid T2D and hypertension. The FGDs were analysed using deductive and inductive thematic approaches. Findings from the survey and qualitative study were integrated in the discussion., Results: Out of a total of 120 respondents who self-reported comorbid T2D and hypertension, 23 (19.2%) provided complete healthcare cost data. The direct cost of managing T2D and hypertension comorbidity constituted almost 94% of the monthly economic cost of care, and the median direct cost of care was US$19.30 (IQR:10.55-118.88). Almost a quarter of the respondents pay for their healthcare through co-payment and insurance jointly, and 42.9% pay out-of-pocket (OOP). Patients with lower socioeconomic status incurred a higher direct cost burden compared to those in the higher socioeconomic bracket. The implications of the high economic burden resulting from self-funding of healthcare were found from the qualitative study to be: 1) poor access to quality healthcare; (2) poor medication adherence; (3) aggravated direct non-medical and indirect cost; and (4) psychosocial support to help cope with the cost burden., Conclusion: The economic burden associated with healthcare in instances of comorbid T2D and hypertension can significantly impact household budget and cause financial difficulty or impoverishment. Policies targeted at effectively managing NCDs should focus on strengthening a comprehensive and reliable National Health Insurance Scheme coverage for care of chronic conditions., (© 2024. The Author(s).)

As economic development advances, there is an increasing focus on improving health conditions, making healthcare expenditure a critical issue worldwide. In China, healthcare spending has shown a marked upward trend, highlighting the importance of understanding its underlying determinants to guide effective policy-making. This study introduces the application of an SV-TVP-FAVAR model to examine the drivers of healthcare expenditure in China from 2007 to 2022. The analysis reveals that economic factors, demographic composition, and policy interventions significantly influence healthcare spending dynamics. Economic growth is strongly linked to increased healthcare expenditure, with economic factors having a particularly pronounced impact during periods of prosperity. Although an aging population drives greater demand for healthcare, the growth rate of healthcare spending has not kept pace with demographic aging, especially following China's economic slowdown. Policy variables present a dual-edged impact: while increased fiscal outlays contribute to budget deficits, limiting the fiscal space for healthcare investment, government emphasis on scientific and technological progress tends to enhance healthcare spending, indicating a synergistic relationship between these areas. Furthermore, the study identifies a prolonged impact of the COVID-19 pandemic on healthcare expenditure, which continues to interact with other driving factors over an extended period. The empirical findings from this research provide crucial evidence to support the development of informed healthcare policies., 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 © 2024 Ge, Cai and Hu.)

Background: Respiratory syncytial virus (RSV) is one of the main causes of hospitalization for lower respiratory tract infection in children under five years of age globally. Maternal vaccines and monoclonal antibodies for RSV prevention among infants are approved for use in high income countries. However, data are limited on the economic burden of RSV disease from low- and middle-income countries (LMIC) to inform decision making on prioritization and introduction of such interventions. This study aimed to estimate household and health system costs associated with childhood RSV in Kenya., Methods: A structured questionnaire was administered to caregivers of children aged < 5 years admitted to referral hospitals in Kilifi (coastal Kenya) and Siaya (western Kenya) with symptoms of acute lower respiratory tract infection (LRTI) during the 2019-2021 RSV seasons. These children had been enrolled in ongoing in-patient surveillance for respiratory viruses. Household expenditures on direct and indirect medical costs were collected 10 days prior to, during, and two weeks post hospitalization. Aggregated health system costs were acquired from the hospital administration and were included to calculate the cost per episode of hospitalized RSV illness., Results: We enrolled a total of 241 and 184 participants from Kilifi and Siaya hospitals, respectively. Out of these, 79 (32.9%) in Kilifi and 21(11.4%) in Siaya, tested positive for RSV infection. The total (health system and household) mean costs per episode of severe RSV illness was USD 329 (95% confidence interval (95% CI): 251-408 ) in Kilifi and USD 527 (95% CI: 405- 649) in Siaya. Household costs were USD 67 (95% CI: 54-80) and USD 172 (95% CI: 131- 214) in Kilifi and Siaya, respectively. Mean direct medical costs to the household during hospitalization were USD 11 (95% CI: 10-12) and USD 67 (95% CI: 51-83) among Kilifi and Siaya participants, respectively. Observed costs were lower in Kilifi due to differences in healthcare administration., Conclusions: RSV-associated disease among young children leads to a substantial economic burden to both families and the health system in Kenya. This burden may differ between Counties in Kenya and similar multi-site studies are advised to support cost-effectiveness analyses., (© 2024. The Author(s).)

Importance: The degree of cancer patients' financial hardship is dynamic and can change over time., Objective: To assess longitudinal changes in financial hardship among patients with early-stage colorectal cancer., Design, Setting, and Participants: In this prospective longitudinal cohort study, English-speaking adult patients with a new diagnosis of stage I to III colorectal cancer being treated with curative intent at National Cancer Institute (NCI) Community Oncology Research Program (NCORP) practices between May 2018 and July 2020 and who had not started chemotherapy and/or radiation were included. Data analysis was conducted from March to December 2023., Main Outcomes and Measures: Patients completed surveys at baseline as well as at 3, 6, 12, and 24 months after enrollment. Cost-related care nonadherence and material hardship, as adopted by Medical Expenditure Panel Survey, were measured. Factors associated with financial hardship were assessed using longitudinal multivariable logistic regression models with time interaction., Results: A total of 451 patients completed baseline questions, with 217 (48.1%) completing the 24-month follow-up. Mean (SD) age was 61.0 (12.0) years (210 [46.6%] female; 33 [7.3%] Black, 380 [84.3%] White, and 33 [7.3%] American Indian or Alaska Native, Asian, multiracial, or Native Hawaiian or Other Pacific Islander individuals or those who did not report race or who had unknown race). Among 217 patients with data at baseline and 24 months, 19 (8.8%) reported cost-related care nonadherence at baseline vs 20 (9.2%) at 24 months (P = .84), and 125 (57.6%) reported material hardship at baseline vs 76 (35.0%) at 24 months (P < .001). In multivariable analysis, lower financial worry (odds ratio [OR], 0.90; 95% CI, 0.87-0.93), higher education (OR, 0.34; 95% CI, 0.15-0.77), and older age (OR, 0.94; 95% CI, 0.91-0.98) were associated with lower nonadherence. Receipt of chemotherapy was associated with higher material hardship (OR, 2.68; 95% CI, 1.15-6.29), while lower financial worry was associated with lower material hardship (OR, 0.83; 95% CI, 0.80-0.96). Over 24 months, female sex was associated with lower nonadherence (OR, 0.90; 95% CI, 0.85-0.96), while higher education was associated with higher nonadherence (OR, 1.09; 95% CI, 1.03-1.17). Being employed was associated with lower material hardship (OR, 0.85; 95% CI, 0.78-0.93), while receipt of care at safety-net hospitals was associated with higher hardship (OR, 1.09; 95% CI, 1.01-1.17)., Conclusions and Relevance: In patients with early-stage colorectal cancer, material hardship was more common than cost-related cancer care nonadherence and decreased over time, while nonadherence remained unchanged. Early and longitudinal financial screening and referral to intervention are recommended to mitigate financial hardship.

Background: Immunotherapy (IO) and oral anticancer agents (OAA) have improved outcomes for metastatic renal cell carcinoma (mRCC), but there is a need to understand real-world costs from the perspective of payers and patients., Methods: We used retrospective fee-for-service Medicare 100% claims data to study patients diagnosed with mRCC in 2015-2019. We identified initial treatment type and costs (the year after diagnosis) and analyzed differences in monthly and 12-month costs over time and between OAA, IO, and combination groups and the association between Out-Of-Pocket (OOP) costs and adherence., Results: We identified 15 407 patients with mRCC (61% male; 85% non-Hispanic White). A total of 6196 received OAA, IO, or combination OAA/IO as initial treatment. OAA use decreased (from 31% to 11%) with a simultaneous rise in patients receiving IO (3% to 26%) or combination IO/OAA therapy (1% to 11%). Medicare payments for all patients with mRCC increased by 41%, from $60 320 (95% confidence interval = 58 260 to 62 380) in 2015 to $85 130 (95% confidence interval = 82 630 to 87 630) in 2019. Payments increased in patients who received OAA, IO, or combination OAA/IO but were stable in those with other/no treatment. Initial higher OOP responsibility ($200-$1000) was associated with 13% decrease in percent days covered in patients receiving OAA in the first 90 days of treatment, compared with those whose OOP responsibility was less than $200., Conclusion: From 2015 to 2019, costs for Medicare patients with mRCC rose substantially due to more patients receiving IO or IO/OAA combined therapy and increases in costs among those receiving those therapies. Increased OOP costs was associated with decreased adherence., (© The Author(s) 2024. Published by Oxford University Press.)

Background: Podoconiosis is a progressive and debilitating form of tropical lymphoedema endemic to Rwanda. Although the physical and psychological consequences are well known, few studies have evaluated the financial burden of podoconiosis., Methods: This cross-sectional, quantitative study aimed to characterize direct treatment costs and impacts on annual earnings among individuals living with podoconiosis. Participants from two highly endemic districts were invited to complete a survey focused on health-seeking history, insurance status, out-of-pocket costs and income changes. Direct treatment costs included medical expenditures (consultation, diagnostics, medication) and non-medical expenditures (food, transportation, accommodation)., Results: Overall, 226 adults (≥18 y of age) diagnosed with podoconiosis participated. Most had access to community-based health insurance (91.6%) but were unable to work (71.7%). Respondents sought care from health centres/posts (61.9%), hospitals (25.1%), traditional healers (5.8%) and/or community health workers (4.0%). On average, study participants paid US$32.50 (range US$0-779.23) annually, or 11.7% of their household salary, on podoconiosis treatments., Conclusions: This study demonstrates the significant financial burden of podoconiosis on individuals and their communities. Increased attention on integrating podoconiosis management into primary care systems and testing cost-effective solutions is needed to protect those who are most vulnerable., (© The Author(s) 2024. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene.)

Objectives: The annual mean spending measures typically used to study longitudinal trends mask distributional and seasonal variation that is relevant to patients' perceptions of health care affordability and, in turn, provider collections. This study describes shifts in the distribution and seasonality of plan and patient out-of-pocket spending from 2012 through 2021., Study Design: Analysis of multipayer commercial claims data., Methods: Medical spending per enrollee was calculated by summing inpatient, outpatient, and professional services, which comprised plan payments and out-of-pocket payments (deductible, coinsurance, co-payment). To account for the long right tail of the spending distribution, enrollees were stratified by their decile of annual medical spending, and annual mean spending estimates were calculated overall and by decile. Mean spending estimates were also calculated by quarter-year., Results: Inflation-adjusted medical spending grew most quickly among the highest decile of spenders, without proportional growth in their out-of-pocket expenses. Out-of-pocket spending increased for the majority of enrollees in our sample prior to the COVID-19 pandemic, in real dollars and as a share of total medical spending. Out-of-pocket spending was increasingly concentrated in the early months of the calendar year, driven by deductible spending, and was lower in 2020 and 2021, plausibly due to policies limiting cost sharing for COVID-19-related services., Conclusions: Insurance is working well to protect the highest spenders at the cost of reduced insurance generosity among spenders elsewhere in the distribution. The increasing cross-subsidization among enrollees through cost-sharing design-vs premiums-is a trend to watch among rising public concerns about underinsurance and medical debt.

High health care prices cause significant harm to individuals, businesses, communities, and society at large. These harms include reduced access to care, rising medical debt, lower wages, more inequity, and a growing burden on businesses and governments. Despite widespread recognition of the issue, there has been insufficient action to address it effectively. Catalyst for Payment Reform and the Employers' Forum of Indiana's new campaign, Price Crisis, will mobilize individuals, employers, and policy makers with evidence, guidance, and resources to take meaningful actions through marketplace initiatives, policy advocacy, and antitrust enforcement. The following article is written from the perspective of Catalyst for Payment Reform.

Objectives: The high costs of cancer care can cause significant harm to patients and society. Prostate cancer, the leading nonskin malignancy in men, is responsible for the second-highest out-of-pocket (OOP) payments among all malignancies. Multiple first-line treatment options exist for metastatic castration-resistant prostate cancer (mCRPC); although their costs vary substantially, comparative effectiveness data are limited. There is little evidence of how gross payments made by insurers and OOP payments made by patients differ by treatment and health plan type and how these payment differences relate to utilization., Study Design: Retrospective cohort study., Methods: We used IBM MarketScan databases from 2013-2019 to identify men with prostate cancer who initiated treatment with 1 of 6 drugs approved for first-line treatment of mCRPC. We calculated and compared gross and OOP payments and drug utilization across drug and insurance plan types., Results: We identified 4298 patients who met our inclusion criteria. Insurer payments varied substantially by first-line therapy but were similar across different health plan types, except for docetaxel. OOP payments for a given first-line therapy, in contrast, varied by health plan type. Utilization of first-line therapies varied by plan type in unadjusted analyses, but not after adjusting for patient characteristics., Conclusions: The extent to which patient OOP payments for drugs reflect differences in gross payments made by insurers varies across health insurance plan types. However, even though OOP payments for the same treatment differ across plan types, treatment choice is not significantly different across type of health insurance after controlling for patient characteristics.

Objectives: The number of commercial beneficiaries cared for by accountable care organizations (ACOs) is growing, but the literature examining their trends is nascent., Study Design: We examined commercial claims data from 2019 to 2021 to compare beneficiaries attributed to participants in Medicare Shared Savings Program ACOs with and without a major teaching hospital., Methods: We calculated mortality and spending by setting for each ACO type by year., Results: Compared with per-beneficiary rates at nonteaching ACOs, major teaching ACOs have lower mortality rates by up to 2.2 percentage points depending on the patient age group, $283 lower inpatient spending, and lower emergency department utilization in inpatient (-0.008) and outpatient (-0.013) settings, as well as $146 higher overall outpatient spending. Upward trends in mortality and beneficiary risk scores across both ACO types show disruption to health outcomes during COVID-19., Conclusions: These results provide evidence that ACOs with major teaching hospitals may be more likely to achieve the value-based goals of ACOs. Means to accomplish those goals may include avoiding higher-intensity care and supporting access to lower-cost alternatives where clinically appropriate, such as reducing inpatient and emergency department stays by delivering timely, high-quality outpatient care.

Background: Mental ill-health-illness or conditions related to mental health, including dementia, schizophrenia, mood (affective) disorders, and mental and behaviour disorders due to psychoactive substance and alcohol use - places a significant burden on society in terms of economic, health, and social costs. Focusing on direct health care costs, estimated expenditures on treating mental health conditions accounted for up to 14% of total health expenditures across 12 OECD countries over the period of 2003 to 2010., Aims of the Study: The purpose of this study was to estimate the direct health care costs associated with the treatment of mental ill-health in Canada for the year 2019 using currently available guidelines. A consistent and systematic method, such as that used in the OECD guidelines on expenditure by disease, age and gender under the System of Health Accounts, can provide valuable information for policy makers and improve comparability of Canadian estimates with those of peer countries., Methods: To derive comprehensive, and internationally comparable estimates of mental health care expenditures, the results were classified according to the OECD System of Health Accounts 2011 for the following cost components: hospitals, physicians, psychologists in private practice, prescription drugs, and community mental health care. Based on data availability, both public and private expenditures were captured. Where data were lacking, estimates were based on the published literature., Results: Total expenditure for mental health care was estimated at $17.1 billion in Canada in 2019. Hospital services (inpatient and outpatient) represent the largest component totaling $5.5 billion or 32% of total mental health spending. They are followed by expenditures on prescribed pharmaceutical drugs of $4.3 billion (25%), community-based care of $3.6 billion (21%), physician services of $2.7 billion (16%) and services of psychologists in private practice of $1.1 billion (6%)., Discussion: The study provided the most recent and comprehensive estimate of mental health expenditure in Canada. The results for similar cost components, are comparable to those found in the previous studies. Expenditures directed towards mental health treatment accounted for 6.4% of total health expenditures, and 6.9% of public health expenditures, in 2019, on par with the OECD average of 6.7% for twenty-three countries. Among considered cost components, community-based mental health and addiction services remain an area where further work is needed the most, including a standardized list of services reported by each Canadian province/territory regardless of care setting, service administrator or funder.  In Canada, data challenges are considerable to assess private spending out-of-pocket or through third-party insurance for services by psychologists or psychotherapists, as well as residential and home care. Given data challenges, the total expenditure estimate is likely conservative.    IMPLICATIONS: Consistent and comparable estimates such as these can be used to better understand how resources are being used in the treatment of mental health, including key cost drivers, and the impact of policy changes, as well as to undertake reliable inter-jurisdictional and international comparisons.

Dual-eligible beneficiaries have insurance through two distinct and uncoordinated programs: Medicaid, which pays for long-term care; and Medicare, which pays for medical care, including hospital stays. Concern that this system leads to poor quality and inefficient care, particularly for dual-eligible nursing home residents, has led policy makers to test managed care plans that provide incentives for coordinating care across Medicare and Medicaid. We examined enrollment in three such plans among dual-eligible beneficiaries receiving long-term nursing home care. Two of those plans, Medicare-Medicaid plans and Fully Integrated Dual Eligible Special Needs Plans, are integrated care plans that establish a global budget including Medicare and Medicaid spending. The third, Institutional Special Needs Plans, puts insurers and nursing homes at risk for Medicare spending but not Medicaid spending. Among dual-eligible nursing home residents, enrollment in these plans increased from 6.5 percent of residents per month in 2013 to 16.9 percent in 2020. Enrollment varied across counties but did not vary appreciably with respect to nursing home characteristics, including the share of residents with Medicaid. As policy makers pursue strategies to coordinate medical and long-term care for dual-eligible beneficiaries, it remains critical to evaluate how these plans influence the care of dual-eligible nursing home residents.

Background: Bronchiectasis carries a significant economic burden with high health care expenditures associated with frequent hospitalizations, physician visits, and treatments, including oral and intravenous antibiotics for repeated lung infections, airway-clearance therapy, and oxygen administration. Bronchiectasis exacerbations can contribute to this burden., Objective: To estimate US health care resource utilization (HCRU) and costs associated with bronchiectasis and with bronchiectasis exacerbations., Methods: This retrospective study used the 100% Medicare Fee-for-Service database (January 2014 to December 2020) to compare HCRU and costs among patients with bronchiectasis with those of patients without bronchiectasis (controls). For patients with bronchiectasis, the index date was a randomly selected bronchiectasis claim after more than 1 year of disease history and, for controls, a claim closest to their matched bronchiectasis patient's index date. All patients had continuous enrollment for at least 12 months pre-index (baseline) and at least 12 months post-index. Primary outcomes were all-cause, respiratory-related, and bronchiectasis-related HCRU and health care costs, which were presented by the overall sample and by segmented patient cohorts based on the number of exacerbations during baseline (0, 1, or ≥2)., Results: 92,529 patients with bronchiectasis (mean [SD] age, 76.7 [8.8] years; 72.3% female) and 92,529 matched controls qualified for the study. Compared with controls, patients with bronchiectasis presented greater mean (SD) all-cause physician visits (15.4 [10.0] vs 13.2 [9.7]; P < 0.001) and respiratory-related physician visits (5.2 [4.3] vs 1.9 [3.1]), pulmonologist visits (1.9 [2.2] vs 0.3 [1.0]), hospitalizations (0.4 [0.9] vs 0.3 [0.8]), emergency department visits (0.33 [1.0] vs 0.26 [1.0]), and total health care costs ($10,224 [$23,263] vs $6,704 [$19,593]). Respiratory-related HCRU was also greater in patients with more baseline exacerbations, with total health care costs of $8,506, $10,365, and $14,790 for patients with 0, 1, and at least 2 exacerbations, respectively ( P < 0.01)., Conclusions: This real-world study demonstrates the high disease burden associated with bronchiectasis and with exacerbations, highlighting the need to improve management and reduce exacerbations.

The introduction of highly effective anti-obesity drugs, such as Wegovy, has prompted debate over Medicare's prohibition on coverage of such products. In this study, we estimated the costs of allowing Medicare coverage of anti-obesity medications. Our analysis incorporated data on drug costs, real-world adherence rates, and potential changes to other health care spending. Using Medicare claims, we also documented beneficiaries' eligibility for nearly identical products approved for different indications. Assuming that anti-obesity drugs were covered in 2025 and that 5 percent or 10 percent of newly eligible patients were prescribed one, annual Part D costs were estimated to increase by $3.1 billion or $6.1 billion, respectively. The marginal costs of this policy could fall by as much as 62.5 percent from baseline estimates if products were approved for additional indications in coming years because these additional conditions are common among people with obesity. This would increase Medicare spending but would occur regardless of a policy change. Longer-term estimates come with significant uncertainty about utilization and price changes, but these results are consistent with this policy change likely increasing Medicare costs by the low to middle tens of billions of dollars over ten years.

Objective: Investigate the association between Telemental Health (TMH) uptake and sociodemographic characteristics, and how TMH uptake relates to health care resource utilization and Medicaid expenditures among Mississippi Medicaid enrollees with major depression. Methods: A retrospective cohort study was conducted (2019-2020), comparing those who utilized TMH and those who did not. Results: Among the 21,239 identified enrollees, 806 (3.79%) utilized TMH. The TMH cohort was more likely to be of older age, non-Hispanic White, comprehensive managed care organization enrollees, rural residents, and from areas with a higher area deprivation index, and have higher Charlson comorbidity index scores. The TMH cohort also exhibited higher mental health-related and all-cause outpatient and emergency department utilization, along with higher Medicaid expenditures. Conclusion: As the first study investigating telehealth utilization among Mississippi Medicaid enrollees, this study highlights sociodemographic disparities in telehealth adoption. Addressing barriers hindering telehealth adoption among vulnerable populations and ensuring the availability of quality data are vital for future research.

Introduction: Universal Health Coverage (UHC) is a widely accepted objective among entities providing development assistance for health (DAH) and DAH recipient governments. One key metric to assess progress with UHC is financial risk protection, but empirical evidence on the extent to which DAH is associated to financial risk protection (and hence UHC) is scarce., Methods: Our sample is comprised of 65 countries whose DAH per capita is above the population -weighted average DAH per capita across all countries. The sample comprises of 1.7 million household observations, for the period 2000-2016. We run country and year fixed effects regressions, and pseudo-panel models, to assess the association between DAH and three measures of financial risk protection: catastrophic health expenditure (i.e., out-of-pocket health expenditures larger than 10% of total household expenditures ['CHE10%']), out-of-pocket health expenditure as a share of total expenditure ('OOP%'), and impoverishment due to health expenditures, at the 1.90US$ per day poverty line ('IMP190')., Results: on average, DAH investment does not appear to be significantly associated with financial risk protection outcomes. However, we find suggestive evidence that a 1 US$ increase in DAH per capita is negatively associated (i.e., an improvement) with at least one financial risk protection outcome for the poorest household quintile within countries (in fixed effects models, IMP190: 0.05 percentage points, p < 0.1; in pseudo-panel models, CHE10%: 0.12 percentage points, p < 0.01). DAH is also negatively associated (i.e., an improvement) with most financial risk protection outcomes when it is largely channelled via government systems (i.e., when it is "on-budget") (CHE10%: 0.68 percentage points, p < 0.05). Several robustness checks confirm these results., Discussion: DAH investments require careful planning to improve financial risk protection. For example, positive DAH effects for the poorest quintiles of the population might be driven by DAH targeting poorer populations and doing so effectively. Our results also suggest that channelling more resources via governments might be a promising avenue to enhance the impact of DAH on financial risk protection., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Progress towards universal health coverage is monitored by the incidence of catastrophic spending. Two catastrophic spending indicators are commonly used in Europe: Sustainable Development Goal (SDG) indicator 3.8.2 and the WHO Regional Office for Europe (WHO/Europe) indicator. The use of different indicators can cause confusion, especially if they produce contradictory results and policy implications. We use harmonised household budget survey data from 27 European Union countries covering 505,217 households and estimate the risk of catastrophic spending, conditional on household characteristics and the design of medicines co-payments. We calculate the predicted probability of catastrophic spending for particular households, which we call LISAs, under combinations of medicines co-payment policies and compare predictions across the two indicators. Using the WHO/Europe indicator, any combination of two or more protective policies (i.e. low fixed co-payments instead of percentage co-payments, exemptions for low-income households and income-related caps on co-payments) is associated with a statistically significant lower risk of catastrophic spending. Using the SDG indicator, confidence intervals for every combination of protective policies overlap with those for no protective policies. Although out-of-pocket medicines spending is a strong predictor of catastrophic spending using both indicators, the WHO/Europe indicator is more sensitive to medicines co-payment policies than the SDG indicator, making it a better indicator to monitor health system equity and progress towards UHC in Europe., Competing Interests: Declaration of competing interest No ethics approval was needed as this analysis uses anonymized, secondary data., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background/objective: Rheumatologic diseases encompass a group of disabling conditions that often require expensive clinical treatments and limit an individual's ability to work and maintain a steady income. The purpose of this study was to evaluate contemporary patterns of financial toxicity among patients with rheumatologic disease and assess for any associated demographic factors., Methods: The cross-sectional National Health Interview Survey was queried from 2013 to 2018 for patients with rheumatologic disease. Patient demographics and self-reported financial metrics were collected or calculated including financial hardship from medical bills, financial distress, food insecurity, and cost-related medication (CRM) nonadherence. Multivariable logistic regressions were used to assess for factors associated with increased financial hardship., Results: During the study period, 20.2% of 41,502 patients with rheumatologic disease faced some degree of financial hardship due to medical bills, 55.0% of whom could not pay those bills. Rheumatologic disease was associated with higher odds of financial hardship from medical bills (adjusted odds ratio, 1.29; 95% confidence interval, 1.22-1.36; p < 0.001) with similar trends for patients suffering from financial distress, food insecurity, and CRM nonadherence (p < 0.001 for all). Financial hardship among patients with rheumatologic disease was associated with being younger, male, Black, and uninsured ( p < 0.001 for all)., Conclusion: In this nationally representative study, we found that a substantial proportion of adults with rheumatologic disease in the United States struggled with paying their medical bills and suffered from food insecurity and CRM nonadherence. National health care efforts and guided public policy should be pursued to help ease the burden of financial hardship for these patients., Competing Interests: The authors declare no conflict of interest., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Objectives: Surgeon sex has been associated with perioperative clinical outcomes among patients undergoing oncologic surgery. There may be variations in financial outcomes relative to the surgeon-patient dyad. We sought to define the association of surgeon's sex with perioperative financial outcomes following cancer surgery., Methods: Patients who underwent resection of lung, breast, hepato-pancreato-biliary (HPB), or colorectal cancer between 2014 and 2021 were identified from the Medicare Standard Analytic Files. A generalized linear model with gamma regression was utilized to characterize the association between sex concordance and expenditures., Results: Among 207,935 Medicare beneficiaries (breast: n = 14,753, 7.1%, lung: n = 59,644, 28.7%, HPB: n = 23,400, 11.3%, colorectal: n = 110,118, 53.0%), 87.8% (n = 182,643) and 12.2% (n = 25,292) of patients were treated by male and female surgeons, respectively. On multivariable analysis, female surgeon sex was associated with slightly reduced index expenditures (mean difference -$353, 95%CI -$580, -$126; p = 0.003). However, there were no differences in 90-day post-discharge inpatient (mean difference -$-225, 95%CI -$570, -$121; p = 0.205) and total expenditures (mean difference $133, 95%CI -$279, $545; p = 0.525)., Conclusions: There was minor risk-adjusted variation in perioperative expenditures relative to surgeon sex. To improve perioperative financial outcomes, a diverse surgical workforce with respect to patient and surgeon sex is warranted., (© 2024 The Author(s). Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Background: Collaborative care integrates mental health treatment into primary care and has been shown effective. Yet even in states where its use has been encouraged, take-up remains low and there are potential financial barriers to care., Objective: Describe patient out-of-pocket costs and variations in referral patterns for collaborative care in Colorado., Research Design: Retrospective observational study using administrative medical claims data to identify outpatient visits with collaborative care. For individuals with ≥1 visit, we measure spending and visits at the month level. Among physicians with billings for collaborative care, we measure prevalence of eligible patients with collaborative care utilization., Subjects: Patients with Medicare, Medicare Advantage, or commercial health insurance in Colorado, 2018-2019., Outcomes: Out-of-pocket costs (enrollee payments to clinicians), total spending (insurer+enrollee payments to clinicians), percent of patients billed collaborative care., Results: Median total spending (insurer+patient cost) was $48.32 (IQR: $41-$53). Median out-of-pocket cost per month in collaborative care was $8.35 per visit (IQR: $0-$10). Patients with commercial insurance paid the most per month (median: $15); patients with Medicare Advantage paid the least (median: $0). Among clinicians billing for collaborative care (n=193), a mean of 12 percent of eligible patients utilized collaborative care; family practice and advanced practice clinicians' patients utilized it most often., Conclusions: Collaborative care remains underused with fewer than 1 in 6 potentially eligible patients receiving care in this setting. Out-of-pocket costs varied, though were generally low; uncertainty about costs may contribute to low uptake., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Health expenditure data almost always include extreme values, implying that the underlying distribution has heavy tails. This may result in infinite variances as well as higher-order moments and bias the commonly used least squares methods. To accommodate extreme values, we propose an estimation method that recovers the right tail of health expenditure distributions. It extends the popular two-part model to develop a novel three-part model. We apply the proposed method to claims data from one of the biggest German private health insurers. Our findings show that the estimated age gradient in health care spending differs substantially from the standard least squares method., 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., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

The scope of this paper was to estimate the prevalence of multimorbidity in the city of São Paulo and to verify the factors associated with the utilization of the health services. It involved a population based cross-sectional study based on data from the Health Survey in the city of São Paulo, in which descriptive analysis was conducted, and logistic regression models were developed using multimorbidity and sociodemographic independent variables, living conditions and use of health services as the outcome. A total of 3,184 individuals aged 20 years or older participated, with a mean age of 43.8 years. The prevalence of multimorbidity was 50.7% among women, 62.5% among those who reported some health problem and 55.1% among those who had recourse to health services in the last 2 weeks. A higher prevalence was identified among those who used the health service due to a mental health problem (66.1%), and in those who reported higher health expenditures in the preceding month (55.4%). Multimorbidity was more frequently associated with aging, in the population with a higher economic status, with worse self-rated health, who frequented health services for 6 months or less, who reported a health problem, or who had a health plan and opted for polypharmacy.

This paper utilizes Benford's law, the distribution that the first significant digit of numbers in certain datasets should follow, to assess the accuracy of self-reported health expenditure data known for measurement errors. We provide both simulation and real data evidence supporting the validity assumption that genuine health expenditure data conform to Benford's law. We then conduct a Benford analysis of health expenditure variables from two widely utilized public datasets, the China Health and Nutrition Survey and the China Family Panel Studies. Our findings show that health expenditure data in both datasets exhibit inconsistencies with Benford's law, with the former dataset tending to be less prone to reporting errors. These results remain robust while accounting for variations in survey design, recall periods, and sample sizes. Moreover, we demonstrate that data accuracy improves with a shorter time interval between hospitalization and interviews, when the data is self-reported as opposed to proxy responses, and at the household level. We find no compelling evidence that enumerators' assessments of respondents' credibility or urgency to end interviews are indicative of data accuracy. This paper contributes to literature by introducing an easy-to-implement analytical framework for scrutinizing and comparing the reporting accuracy of health expenditure data., Competing Interests: Declaration of competing interest None., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Purpose: To quantify the preferences for an oral antidiabetic drug (OAD) among patients with type 2 diabetes mellitus (T2DM) in China., Methods: A discrete choice experiment (DCE) with hypothetical OAD profiles was performed among patients with T2DM recruited from both online and offline sources. Each patient completed 12 DCE choice tasks. The attributes, elicited through mixed methods, include blood glucose level decrease, blood glucose level stability, frequency of medication, gastrointestinal side effects, dose adjustment and out-of-pocket expense. The conditional logit regression model was used to analyze the data. Patients' willingness-to-pay (WTP) was also calculated. Subgroup analyses based on patient characteristics were also conducted., Results: A total of 741 respondents were included in the analysis sample, covering 456 respondents online and 285 offline. The result showed that all attributes and levels were statistically significant, except one level "dose adjustment required for patients with hepatic or renal insufficiency" in the attribute of dose adjustment. WTP results showed that patients were willing to pay 12.06 and 23.20 yuan, respectively to reduce the frequency of medication from "once per day" and "three times per day" to "once every 2 weeks", respectively. Subgroup analyses showed that the frequency of medication (once versus two to three times per day) had the largest impact and influenced most coefficient estimates., Conclusion: The results suggest that Chinese patients with T2DM prioritized better efficacy, less frequency of medication, lower gastrointestinal side effects, no dose adjustment required for patients with hepatic or renal insufficiency, and less out-of-pocket expense of OAD treatment., (© 2024. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Background: Recent practice guidelines favor direct oral anticoagulants (DOACs) over warfarin for primary stroke prevention in patients with non-valvular atrial fibrillation (NVAF). However, challenges persist in Iraq's private pharmaceutical sector. DOACs have been sold at high and inconsistent retail prices and lack insurance coverage, leading to significant out-of-pocket (OOP) costs. The objective of this study is to investigate the impact of OOP costs on oral anticoagulants (OAC) adherence among NVAF patients., Research Design and Methods: This multicenter cross-sectional study interviewed 359 eligible patients attending three private cardiology clinics within Iraq's southern region from December 2022 to February 2023. The 8-item Morisky Adherence Scale evaluated patient adherence. Statistical analyses, including descriptive analysis, ANOVA, and chi-square. p  < 0.05 was considered statistically significant., Results: The most frequently prescribed OAC were DOACs (62.8%). Patient adherence level to OAC was chiefly medium (54.6%) with no significant difference in adherence based on OAC type. Patient adherence was significantly associated with monthly income ( p  = 0.001), number of daily pills ( p  = 0.006), and OACs' average monthly cost ( p  = 0.011)., Conclusion: Addressing the issue of cost-related non-adherence to OACs requires multiple actions. These include ensuring comprehensive health insurance coverage for OACs, increasing the use of affordable generic alternatives, and establishing effective cost-related discussions between healthcare providers and patients.

Background: Targeted cancer drugs (TCDs) have revolutionized oncology but vary in clinical benefit and patient out-of-pocket (OOP) costs. The American Society of Clinical Oncology (ASCO) Value Framework uses survival, toxicity, and symptom palliation data to quantify the net health benefit (NHB) of cancer drugs. We evaluated associations between NHB, uptake, and spending on oral TCDs., Methods: We conducted a retrospective cohort study of patients aged 18-64 years with an incident oral TCD pharmacy claim in 2012-2020 in a nationwide deidentified commercial claims dataset. TCDs were categorized as having high (>60), medium (40-60), and low (<40) NHB scores. We plotted the uptake of TCDs by NHB category and used standard descriptive statistics to evaluate patient OOP and total spending. Generalized linear models evaluated the relationship between spending and TCD NHB, adjusted for cancer indication., Results: We included 8524 patients with incident claims for 8 oral TCDs with 9 first-line indications in advanced melanoma, breast, lung, and pancreatic cancer. Medium- and high-NHB TCDs accounted for most TCD prescriptions. Median OOP spending was $18.78 for the first 28-day TCD supply (interquartile range [IQR] = $0.00-$87.57); 45% of patients paid $0 OOP. Median total spending was $10 118.79 (IQR = $6365.95-$10 600.37) for an incident 28-day TCD supply. Total spending increased $1083.56 for each 10-point increase in NHB score (95% confidence interval = $1050.27 to $1116.84, P < .01 for null hypothesis H0 = $0)., Conclusion: Low-NHB TCDs were prescribed less frequently than medium- and high-NHB TCDs. Total spending on oral TCDs was high and positively associated with NHB. Commercially insured patients were largely shielded from high OOP spending on oral TCDs., (© The Author(s) 2024. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Organization for Economic Co-operation and Development (OECD) countries have embraced the aim of universal health coverage, as established in Sustainable Development Goal (SDG) 3.8. This goal guarantees access to quality healthcare services without financial hardship or poverty. Additionally, it requires correct and adequate financing sources. A country with weak protection for its population tends to spend less on healthcare and experiences a high share of out-of-pocket payments (OOPs), increasing the likelihood of people falling into poverty. This study aims to understand the relationship and causal effects between macroeconomic and public fiscal conditions and private health expenditure in OECD countries between 1995 and 2019. We retrieved OECD data for 26 OECD countries for the period 1995-2019. Panel AutoRegressive Distributed Lag (PARDL) and panel quantile AutoRegressive Distributed Lag (PQARDL) models were estimated to examine the relationship between private health expenditures and macroeconomic and public fiscal variables. Our results reveal a positive influence of government debt and economic freedom on private health expenditures. They also show a negative influence of the government budget balance, government health expenditures, and economic growth on private health expenditures. These results collectively suggest that public fiscal conditions will likely impact private health expenditures. The findings of this study raise concerns about the equity and financial protection objectives of universal health coverage in OECD countries., (© 2024. The Author(s).)

Catastrophic out-of-pocket health expenditure (CHE) remain high in Sub-Saharan Africa and may not conform to the sporadic random pattern of acute illnesses that shapes insurance arrangements intended to avoid the risk of financial loss. The persistency of CHE remains a largely unexplored issue due to the lack of relevant methods and scarcity of panel data. This paper addresses the first shortcoming by presenting three different approaches to incorporating the timeframes into the analysis, considering dynamics between two periods, average over time and the recurrence of CHE incidence. Through the application of the complementary approaches, we identify (i) those at risk of persistent CHE in the short-term; (ii) those facing transient versus persistent CHE in the long-term; and (iii) those facing multiple CHE spells. The methods are applied to different definitions of CHE using panel data from three sub-Saharan countries: Malawi (3 waves: 2010, 2013, and 2016) with 4983 observations; Tanzania (3 waves: 2008, 2010, and 2012) with 8715 observations; and Uganda (5 waves: 2009, 2010, 2011, 2013, and 2015) with 6475 observations. All datasets are balanced panels. Additionally, we employ empirical strategies to identify the underlying factors contributing to these persistent and relatively high OOP. Across the three countries, we find that at least 27% of the people facing CHE in one period, because they spent more than 5% of their household budget on health out-of-pocket, will face it again in the next period. The lower-bound risk for those spending more than 10% of their household budget is 9% and for those spending more than 25% of their household capacity to pay is 13%. Between 11% and 45% of the population incurred CHE at least twice during the observation period when using the 5% budget definition of CHE. The double recurrence rate ranges between 7% and 13% when using the 25% capacity-to-pay definition and between 3% and 20% when using the 10% budgetshare definition. Between 22% and 32% of the population experienced chronic CHE at the 5% of the budgetshare definition (6%-10% at the 10% of the budgetshare definition of CHE; 2%-11% at 25% of capacity-to-pay). Our panel regression analysis consistently highlights the susceptibility of certain groups to face persistence CHE, notably those residing in rural areas, individuals with lower levels of education, the elderly, and those who have undergone hospitalizations., (Copyright © 2024. Published by Elsevier Ltd.)

Demand-side cost-sharing reduces moral hazard in healthcare but increases exposure to out-of-pocket expenditure. We introduce a structural microsimulation model to evaluate both total and out-of-pocket expenditure for different cost-sharing schemes. We use a Bayesian mixture model to capture the healthcare expenditure distributions across different age-gender categories. We estimate the model using Dutch data and simulate outcomes for a number of policies. The model suggests that for a deductible of 300 euros shifting the starting point of the deductible away from zero to 400 euros leads to an average 4% reduction in healthcare expenditure and 47% lower out-of-pocket payments., 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., (Copyright © 2024 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Asthma, a chronic respiratory disease, is associated with high economic burden. This study estimates per-worker medical and incremental medical costs associated with treated asthma by socioeconomic and demographic characteristics, industries, medical events, and sources of payments for workers aged ≥18 years., Methods: We analyzed Medical Expenditure Panel Survey data from 2018 to 2020 to assess medical costs for treated asthma among workers using the International Classification of Diseases, Tenth Revision, Clinical Modification code for asthma (J45). We used two-part regression models to estimate medical and incremental medical costs controlling for covariates. All results are adjusted for inflation and presented in 2022 US dollar values., Results: An estimated annual average of 8.2 million workers out of 176 million had at least one medical event associated with treated asthma. The annualized estimated per-worker incremental medical costs for those with treated asthma was $457 and was highest among: those in the age group of 35-44 years ($534), in the western region ($768), of Hispanic ethnicity ($693), employed in the utility and transportation industries ($898), males ($650), and for inpatient admissions ($754). The total annualized medical costs of treated asthma was $21 billion and total of incremental medical costs was $3.8 billion., Conclusion: Findings of higher incremental medical costs for treated asthma among workers in certain socioeconomic, demographic, and industry groups highlight the economic benefit of prevention and early intervention to reduce morbidity of asthma in working adults. Our results suggest that the per-person incremental medical costs of treated asthma among workers are lower than that for all US adults., (© 2024 Wiley Periodicals LLC.)

Background: This study examines incidence, mortality, medical expenditure and prescription patterns for asthma on a national scale, particularly in Asian countries for asthma is limited. Our aim is to investigate incidence, mortality, prescription patterns and provide a comprehensive overview of healthcare utilization trends for asthma from 2009 to 2018., Methods: We included patients diagnosed with asthma between 2009 and 2018. We excluded patients with missing demographic data. Our analysis covered comorbidities, including diabetes mellitus, hypertension, allergic rhinitis, eczema, atopic dermatitis, coronary artery disease, congestive heart failure, chronic kidney disease, chronic hepatitis, stroke, and cancer. Investigated medications comprised oral and intravenous steroids, short-acting beta-agonists, inhaled corticosteroids (ICS), combinations of ICS and long-acting beta-agonists, long-acting muscarinic antagonists, and leukotriene receptor antagonists montelukast. We also assessed the number of outpatient visits, emergency visits, and hospitalizations per year, as well as the average length of hospitalization and average medical costs., Results: The study included a final count of 88,244 subjects from 1,998,311 randomly selected samples between 2000 and 2019. Over the past decade, there was a gradual decline in newly diagnosed asthma patients per year, from 10,140 to 6,487. The mean age annually increased from 47.59 in 2009 to 53.41 in 2018. Over 55% of the patients were female. Eczema was diagnosed in over 55% of the patients. Around 90% of the patients used oral steroids, with a peak of 97.29% in 2018, while the usage of ICS varied between 86.20% and 91.75%. Intravenous steroids use rose from 40.94% in 2009 to 54.14% in 2018. The average annual hospital stay ranged from 9 to 12 days, with a maximum of 12.26 days in 2013. Lastly, the average medical expenses per year ranged from New Taiwan dollars 5558 to 7921., Conclusions: In summary, both asthma incidence and all-cause mortality rates decreased in Taiwan from 2009 to 2018. Further analysis of medical expenses in patients with asthma who required multiple hospitalizations annually revealed an increase in outpatient and emergency visits and hospitalizations, along with longer hospital stays and higher medical costs., (© 2024. The Author(s).)

Objective: To evaluate age-specific multimorbidity patterns and morbidity burden on mortality and healthcare expenditure across age groups., Patients and Methods: Retrospective observational study between January 1, 2009 to December 31, 2017 using electronic health records in Hong Kong: Individuals were stratified by age (< 50, 50-64, 65-79, ≥ 80), and sub-classified by number of morbidities (0, 1, 2, 3, ≥ 4) out of 21 common chronic conditions. Clustering analyses were conducted to identify specific patterns of multimorbidity. Association between the number as well as combinations of morbidities and all-cause mortality and public expenditure was examined., Results: 4,562,832 individuals with a median follow-up of 7 years were included. Mental disorders were the top morbidities among young individuals, while cardiovascular diseases were prevalent in the elderly. An increased number of morbidities was associated with a greater relative risk for mortality and medical expenditure, and this relationship was stronger among younger patients. Compared to individuals in the same age group without morbidity, the hazard ratios (HR; 95% CI) of all-cause mortality in patients aged < 50 and ≥ 80 with two comorbidities 3.81 (3.60-4.03) and 1.38 (1.36-1.40), respectively, which increased to 14.22 (9.87-20.47) and 2.20 (2.13-2.26), respectively, as the number of morbidities increased to ≥ 4. The stroke-hypertension cluster was shown to be associated with the highest HR of mortality 2.48 (2.43-2.53) among all identified clusters arising from the clustering analysis., Conclusion: Given the stronger association between multimorbidity and all-cause mortality and greater opportunity costs in younger populations, prevention and management of early-onset multimorbidity are warranted. (248 words)., (© 2024. The Author(s).)

Background: We sought to assess the impact of telemedicine on healthcare utilization and medical expenditures among patients with a diagnosis of gastrointestinal (GI) cancer., Methods: Patients with newly diagnosed GI cancer from 2013 to 2020 were identified from the IBM MarketScan database (IBM Watson Health) . Healthcare utilization, total medical outpatient insurance payments within 1 year post-diagnosis, and out-of-pocket (OOP) expenses among telemedicine users and non-users were assessed after propensity score matching (PSM)., Results: Among the 32,677 patients with GI cancer (esophageal, n = 1862, 5.7%; gastric, n = 2009, 6.1%; liver, n = 2929, 9.0%; bile duct, n = 597, 1.8%; pancreas, n = 3083, 9.4%; colorectal, n = 22,197, 67.9%), a total of 3063 (9.7%) utilized telemedicine. After PSM (telemedicine users, n = 3064; non-users, n = 3064), telemedicine users demonstrated a higher frequency of clinic visits (median: 5.0 days, IQR 4.0-7.0 vs non-users: 2.0 days, IQR 2.0-3.0, P < .001) and fewer potential days missed from daily activities (median: 7.5 days, IQR 4.5-12.5 vs non-users: 8.5 days, IQR 5.5-13.5, P < .001). Total medical spending per month and utilization of emergency room (ER) visits for telemedicine users were higher vs non-users (median: $10,658, IQR $5112-$18,528 vs non-users: $10,103, IQR $4628-$16,750; 46.8% vs 42.6%, both P < .01), whereas monthly OOP costs were comparable (median: $273, IQR $137-$449 for telemedicine users vs non-users: $268, IQR $142-$434, P = .625)., Conclusion: Telemedicine utilization was associated with increased outpatient clinic visits yet reduced potential days missed from daily activities among patients with GI cancer. Telemedicine users tended to have more ER visits and total medical spending per month, although monthly OOP costs were comparable with non-users., (Copyright © 2024 Society for Surgery of the Alimentary Tract. Published by Elsevier Inc. All rights reserved.)

To investigate household vulnerability for inability to cope with medical expenditure shock, we propose a method of measuring household vulnerability to medical expenditure shock by allowing for the heteroscedasticity and dependence of medical expenditure shock and income shock. Using the data from China Health and Nutrition Survey, we estimate the vulnerability of Chinese households, and further investigate crucial characteristics associated with it by comparing the vulnerability levels among groups with different characteristics and an empirical regression with Shorrocks-Shapely decomposition of R squared. Our research shows that health status contributes most to the household vulnerability, and good health helps to reduce the household's vulnerability. Households with stable income and high-education have greater ability to cope with uncertain medical expenditure, and are less vulnerable. Medical insurance plays a limited role in reducing household vulnerability, and the specific type of medical insurance has little influence. All of these findings are conducive to identifying vulnerable households and designing policies to reduce the vulnerability of households., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The magnitude of the impact of technological innovations on healthcare expenditure is unclear. This paper estimated the impact of high-technology procedures on public healthcare expenditure for patients with ischemic heart disease (IHD) in Portugal. The Blinder-Oaxaca decomposition method was applied to Portuguese NHS administrative data for IHD discharges during two periods, 2008-2015 vs. 2002-2007 (N = 434,870). We modelled per episode healthcare expenditures on the introduction of new technologies, adjusting for GDP, patient age, and comorbidities. The per episode healthcare expenditure was significantly higher in 2008-2015 compared to 2002-2007 for IHD discharges. The increase in the use of high-technology procedures contributed to 28.6% of this growth among all IHD patients, and to 18.4%, 6.8%, 11.1%, and 29.2% for acute myocardial infarction, unstable angina, stable angina, and other IHDs, respectively. Changes in the use of stents and embolic protection and/or coronary brachytherapy devices were the largest contributors to expenditure growth. High-technology procedures were confirmed as a key driver of public healthcare expenditure growth in Portugal, contributing to more than a quarter of this growth., (© 2024. The Author(s).)

Objectives: To measure associations between employment precarity and mental health among United States (US) workers., Methods: This study used data from the US Medical Expenditure Panel Survey for 2008-2021. Multivariable generalized estimating equations were used to measure associations between employment precarity (operationalized as a multi-dimensional exposure) and self-rated mental health after adjusting for relevant confounders. Marginal effects analysis was used to assess potential dose-response relationships between precarity and mental health., Results: Our sample (n = 57,529) was representative of >106 million US workers employed throughout 2008-2021. Compared to those with low levels of employment precarity, those with medium and high levels of precarity had an increased odds of reporting poor/fair mental health (aOR = 1.21; 95% CI = 1.11, 1.32 and 1.51; 95% CI = 1.36, 1.68, respectively). Marginal effects analysis indicated that increasing levels of precarity were associated with an increased probability of reporting poor/fair mental health., Conclusions: Increasing levels of employment precarity were associated with poor/fair self-rated mental health, findings potentially indicative of a dose-response relationship between the two. These nationally representative findings suggest employment precarity is an important social determinant of mental health. Future research could investigate how best to mitigate the negative effects of precarity on workers' lives and well-being, particularly regarding mental health., Competing Interests: Declaration of competing interest The authors have no conflicts of interest or funding sources to disclose., (Copyright © 2024. Published by Elsevier Inc.)

Study Objective: We sought to quantify differences in total and out-of-pocket health care costs associated with treat-and-release emergency department (ED) visits among older adults with traditional Medicare and Medicare Advantage., Methods: We conducted a repeated cross-sectional analysis of treat-and-release ED visits using 2015 to 2020 data from the Medicare Current Beneficiary Survey. We measured total and out-of-pocket health care spending during 3 time periods: the 30 days prior to the ED visit, the treat-and-release ED visit itself, and the 30 days after the ED visit. Stratified by traditional Medicare or Medicare Advantage status, we determined median total costs and the proportion of costs that were out-of-pocket., Results: Among the 5,011 ED visits by those enrolled in traditional Medicare, the weighted median total (and % out-of-pocket) costs were $881.95 (13.3%) for the 30 days prior to the ED visit, $419.70 (10.1%) for the ED visit, and $809.00 (13.8%) for the 30 days after the ED visit. For the 2,595 ED visits by those enrolled in Medicare Advantage, the weighted median total (and % out-of-pocket) costs were $484.92 (24.0%) for the 30 days prior to the ED visit, $216.66 (21.9%) for the ED visit, and $439.13 (22.4%) for the 30 days after the ED visit., Conclusion: Older adults insured by Medicare Advantage incur lower total health care costs and face similar overall out-of-pocket expenses in the time period surrounding emergency care. However, a higher proportion of expenses are out-of-pocket compared with those insured by traditional Medicare, providing evidence of greater cost sharing for Medicare Advantage plan enrollees., (Copyright © 2024 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

The financial impact of liver transplantation has been underexplored. We aimed to identify associations between high financial burden (≥10% annual income spent on out-of-pocket medical costs) and work productivity, financial distress (coping behaviors in response to the financial burden), and financial toxicity (health-related quality of life, HRQOL) among adult recipients of liver transplant. Between June 2021 and May 2022, we surveyed 207 adult recipients of liver transplant across 5 US transplant centers. Financial burden and distress were measured by 25 items adapted from national surveys of cancer survivors. Participants also completed the Work Productivity and Activity Impairment and EQ-5D-5L HRQOL questionnaires. In total, 23% of recipients reported high financial burden which was significantly associated with higher daily activity impairment (32.9% vs. 23.3%, p =0.048). In adjusted analyses, the high financial burden was significantly and independently associated with delayed or foregone medical care (adjusted odds ratio, 3.95; 95% CI, 1.85-8.42) and being unable to afford basic necessities (adjusted odds ratio, 5.12; 95% CI: 1.61-16.37). Recipients experiencing high financial burden had significantly lower self-reported HRQOL as measured by the EQ-5D-5L compared to recipients with low financial burden (67.8 vs. 76.1, p =0.008) and an age-matched and sex-matched US general population (67.8 vs. 79.1, p <0.001). In this multicenter cohort study, nearly 1 in 4 adult recipients of liver transplant experienced a high financial burden, which was significantly associated with delayed or foregone medical care and lower self-reported HRQOL. These findings underscore the need to evaluate and address the financial burden in this population before and after transplantation., (Copyright © 2024 American Association for the Study of Liver Diseases.)

Medical imaging is essential for the proper diagnosis and treatment of many diseases. The literature has found that medical imaging generally accounts for a significant percentage of total healthcare spending. We analyzed a national database between 2013 and 2021, with more than 19 million patients on average, to review which health conditions account for the highest spending on medical imaging in the Colombian health system. We segmented the analysis by type of medical imaging, life cycles, health condition and sex. Our findings indicate that cardiac and mental illnesses account for the highest per capita spending on medical imaging, especially for the elderly. As a proportion of total expenditure, hypertension and tuberculosis are added, with special emphasis on the infancy-childhood life cycle., 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 research., (Copyright © 2024 Elsevier Inc. All rights reserved.)

This study aimed to vividly describe the direct and severe health impacts of conflict in the Eastern Mediterranean Region (EMR) using data from the Global Burden of Disease (GBD). It also sought to quantify the staggering portion of economic damage attributable to the health burden of conflict and terrorism. From 1990 to 2019, the region endured the devastating effects of conflict and terrorism. These circumstances led to 64%, 50%, and 35% of all causes of Disability-Adjusted Life Years (DALYs) in Libya, Syria, and Palestine, respectively, in 2011, 2016, and 2008. These figures represent not just statistics but the profound human cost of these conflicts. The health-related economic burden (HEB) due to conflict was estimated at $4.6 billion in Iraq, $3.7 billion in Afghanistan, and $1.7 billion in Libya in current international dollars. However, due to missing data, the HEB could not be calculated for Yemen and Syria despite significant conflict-related DALYs. In 2019, the HEB to Current Health Expenditure (CHE) ratio, which indicates the proportion of the health-related economic burden compared to health expenditure, was 30% in Afghanistan and 25% in Iraq. This high ratio underscores the significant strain that conflict places on the health systems.

The aim of this study was to explore how medical resources and vaccine coverage relate to infant mortality rate (IMR) and under-five mortality rate (U-5MR), which are both key national health indicators. This longitudinal study was based on panel data from the national level of 200 countries. Data from 1990 to 2021 were grouped into seven regions based on geographic and epidemiological similarities. Regarding correlation, the high-income region showed a different trend from that shown by other regions. Health expenditure was positively associated with IMR and U-5MR globally. Number of medical doctors per 1,000 people was negatively associated with IMR and U-5MR globally. Hepatitis type B (HBV) and measles, first dose (MCV) were negatively associated with IMR and HBV, MCV, and Bacillus Calmette-Guérin were negatively associated with U-5MR globally. In quadratic regression, the correlation between the number of doctors and mortality stabilizes or plateaus at approximately four individuals. Overall vaccine coverage was positively correlated with mortality up to a certain threshold, beyond which it became negatively correlated. A higher number of doctors was consistently associated with decreased mortality, regardless of location, while other factors varied by region. Our study findings highlight the importance of implementing global strategies that are specific to each region's characteristics to reduce IMR and U-5MR., Competing Interests: Declaration of Conflicting InterestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

A primary goal of the New Rural Cooperative Medical Insurance (NRCMI) is to provide financial protection against health care costs and alleviate the financial burdens of rural residents in China. This article examines whether NRCMI participation impacted the incidence of catastrophic health expenditure (CHE) among middle-aged and older adults (45 years old and above). The analysis utilized data from the 2007 China Household Income Project survey in rural areas and an instrumental variable estimation method in Anhui and Sichuan provinces, which exhibited heterogeneity in the NRCMI implementation schedule. The results show that NRCMI participation was not associated with changes in the CHE incidence among families. The finding is consistent with the prior literature using quasi-experimental study designs. This study provides empirical evidence for policymakers, highlighting that the impact of NRCMI participation on financial protections is limited despite its extensive population coverage. The limited effects are probably due to the low reimbursement rate and increased utilization of expensive health care services., Competing Interests: Declaration of Conflicting InterestsThe author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

For the last four decades, policymakers have attempted to control the United States's high health care costs by reducing patients' demand for care (e.g., by imposing managed-care restrictions or high costs on patients at the time of use). Yet studies based mostly on data from the public Medicare program, which covers mostly elderly Americans, suggest that supply (e.g., number of physicians or hospital beds) rather than demand drives aggregate service use and, hence, costs. Using variation between U.S. states in per enrollee Medicare spending versus per capita spending of all other (non-Medicare) individuals, we find that greater supply boosts costs for the entire population. Furthermore, we find that factors that suppress demand in the non-Medicare population do reduce non-Medicare health care spending, but simultaneously increase Medicare spending. This suggests that for a given supply of medical resources, suppressing demand for one group of patients may produce a compensatory increase in provision of care to those whose demand has not been suppressed. Health planning to assure adequate medical resources where they are needed while preventing excess supply where it is duplicative and wasteful is likely a more effective cost control strategy than the imposition of managed-care restrictions or imposing higher costs onto patients seeking care., Competing Interests: Declaration of Conflicting InterestsThe authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Dr. Gaffney is a former president Physicians for a National Health Program (PNHP), a non-profit organization that favors coverage expansion through a single payer program. Adam Gaffney's spouse is an employee of Treatment Action Group (TAG), a non-profit research and policy think tank focused on HIV, TB, and hepatitis C treatment.