Does cost sharing do more harm or more good? - a systematic literature review

Abstract

BackgroundThere are positive and negative consequences of the implementation of out of pocket (OOP) payments as a source of the healthcare financing. On the one hand, OOP burden increases awareness of treatment costs and limits unnecessary use of healthcare services. On the other hand, it may prevent the sick from accessing needed care. Consequently there are several aspects that ought to be taken into consideration while defining the optimal structure of OOP payments. The objective of this study was twofold. Firstly, it was to understand what actions are taken to decrease the OOP burden. Secondly, it was to address the question whether the implementation of any form of formal OOP payments may impact negatively upon fairness in financial contribution.MethodsThe literature search was conducted using the Pubmed, Embase, Cochrane Library and Center of Review and Dissemination databases. Only studies which measured the Kakwani index of progressivity in at least two time points were included. Articles written in English published between January 2004 and September 2015 were searched. No geographical restriction was imposed. An increment of more than 0.10 in the Kakwani index was considered as a significant health policy impact.ResultsIn total 16 publications were included, of which nine studied attempts to decrease the OOP burden, four described the consequences of the introduction of formal fees, and three covered both topics. Overall, a significant health policy impact was noted in four cases. All of them related to a reduction in the OOP burden, with three and one noting a change towards the progressivity and regressivity of direct healthcare payments respectively. Among jurisdictions which introduced formal fees, none study noted a significant impact on the regressivity of OOP spendings.ConclusionsIn the majority of cases, a health policy impact on the distribution of OOP health payments was insignificant. The reduction of OOP burden cannot be achieved successfully without adequate extension of healthcare coverage or engagement of other sources of healthcare financing. When formal fees are being introduced, protection against catastrophic healthcare payments is needed for the most vulnerable groups.

New insight into the informal patients’ payments on the evidence of literature: a systematic review study

“…The common methods for financing the health care services are taxes, social insurance, private health insurance, and out-of-pocket payment [3]. At the timed that a government is unable to properly finance healthcare system, the burden of funding will directly affect the people, and they have to pay for health services by themselves [4]. Direct payments made by individuals to health care providers at the time of service use is known as out-of-pocket payments (OOPs), which is the weakest and most unfair payment mechanism in health care system [5].…”

Out-of-pocket payments, vertical equity and unmet medical needs in France: A national multicenter prospective study on lymphedema

“…Cost-sharing mechanisms have constantly been associated with reduced health care utilization and expenditures since the seminal RAND experiment [40]. But the consequences on health status are controversial: greater cost sharing is associated with reduced use of unnecessary care but also with reduction in utilization of high-value care such as long-term medications and preventive services [41, 42]. Our study suggests that patients facing out-of-pocket costs regarding ambulatory care for chronic oedema declare unmedical medical needs more often than the general population (31% vs. 26%, though figures are not directly comparable).…”

Effects of mixed provider payment systems and aligned cost sharing practices on expenditure growth management, efficiency, and equity: a structured review of the literature

“…Studies have identified positive and negative consequences of the implementation of cost sharing mechanisms for health financing. Out-of-pocket payment for health care may limit unnecessary use of health services, but may also impose barriers to seek care among the sick [13]. The incentives of cost sharing mechanisms operate within the context of the other incentives set through PPMs that providers face.…”

“…Evidence solely focusing on the effects of cost sharing mechanisms (without considering the interaction with supply-side measures) is mixed. Reviews of high-income countries determined that cost sharing for health care was not associated with a decrease in health expenditure and did not appear to significantly affect health care utilization or the distribution of out-of-pocket spending [12, 13]. On the other hand, drug cost sharing and reimbursement caps have been associated with reduced control of hypertension and hypercholesterolemia among US Medicare and Medicaid patients [14–16].…”