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Table 5 Selected Studies on out of pocket reducing strategies

From: Strategies for reducing out of pocket payments in the health system: a scoping review

N

Title

Author

Year

Place

Type

Participants

Results

1

Disease-specific out-of-pocket healthcare expenditure in urban Bangladesh: a Bayesian analysis

Md. Mahfuzur Rahman

2020

Bangladesh

Research Article

Urban areas of Rajshahi

1593 households

-Reducing out of pocket payments, after implementing government supported/public not private health insurance program in LMIC countries, particularly Vietnam, China, and the Philippines

-To avoid unpredictable medical expenses, the Government of Bangladesh should start health insurance program in its health-financing unit

-Implementation of a subsidy program for diseases with high economic burden like renal diseases, cancer, and heart diseases

-More attention to prevent and control chronic diseases

2

Over Medication and Waste of Resources in Physicians’ Prescriptions: a Cross Sectional Study in Southwestern Iran

Mohammadreza Heydari

2020

Iran

Research Article

392 physicians

-Training the physicians

-Developing clinical guidelines

3

The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh

Jahangir A. M. Khan

2020

Bangladesh

Original Article

1292 (646 insured and 646 uninsured) households

-The CBHI scheme (community-based health insurance), and could push the country towards universal health coverage

4

Strategies to Reduce Out-of-Pocket Medication Costs for Canadians Living with Heart Failure

William F. McIntyre

2020

Canada

Original Article

Outpatient pharmacies in Hamilton, Ontario

-Prescription content, dispensing practice, and pharmacy choice can remarkably impact out-of-pocket costs for HF medications

-Prescribers can reduce costs by writing 90-day prescriptions and choosing the lowest-cost generic drugs in each therapeutic class

-Patients should request inexpensive generic drugs

5

Economic Implications of Chinese Diagnosis-Related Group–Based Payment Systems for Critically Ill Patients in ICUs

Zhaolin Meng, MMed

2020

China

Original Research

6679 critically ill patients who received intensive care in the 22 public hospitals)

-Chinese diagnosis-related group, (C-DRG)–based payment system achieved success in reducing OOP payments for critically ill patients by shifting the payment of OOP costs from FFS to DRG

6

Factors associated with disparities in outof-pocket expenditure on dental care: results from two cross-sectional national surveys

Orenstein, L

2020

Occupied Pelastine

Original Research Article

8465 households in 2014 and 8792 households

-Expanding the dental health reform and addressing barriers to preventive dental care

-Expanding basic and supplementary dental health insurance

7

A new hope: from neglect of the health sector to aspirations for Universal Health Coverage in Myanmar

Alex Ergo1

2019

Myanmar

Original Paper

3648 households in Myanmar

-Confidence of services delivery are available at public facilities

-The availability of services closer by

-Improve effectiveness of services

-Necessary drugs and medical supplies should be available at the public facility

8

Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: a national cross-sectional survey

Ivlabèhiré Bertrand Meda

2019

Burkina Faso

Original Research

Women (n = 593) who had delivered or received obstetric care on the day of the survey

-Free maternal health care policy

-Antenatal care, normal deliveries and EmONC, curative care during pregnancy and up to 42 days after delivery, treatment of obstetric fistulas, screening and in situ treatment of precancerous cervical lesions for women between 25 and 55 years old and clinical screening for breast cancer starting at age 15

-Improvements in the management and supply system of health facilities’ pharmacies

9

Financial risk protection at the bedside: how Ethiopian physicians try to minimize out of pocket health expenditures

Ingrid Miljeteig

2019

Ethiopia

Research Article

565 physicians

-Limiting prescription of brand named drugs/hospital drugs

-Explaining alternatives and recommending affordable options

-Limiting x-ray and ultrasound orders

-Providing second best treatment

-Limiting screening tests

-Limiting advanced lab tests

-Limiting ward/ICU admission

-Discharging patients earlier than you wanted

-Limiting surgery unless highly indicated

-Delaying a treatment or test to see if possible to do without it

-Referring patients to other less expensive options

-Providing less frequent follow up of NCDs (chronic conditions)

-Limiting CT or MRI orders

-Not informing the patient about expensive options

-Screening patient for dialysis

-Refuse expensive drug requested by patients or families

10

Health financing strategies to reduce out-of-pocket burden in India: a comparative study of three states

Montu Bose

2018

India

Comparative Study

Research Article

3917 households from TN, 2912 households in Rajasthan and 5019 households from WB

-Procuring medicine or regularly updating the essential list of drugs according to need of patients are urgently required in West Bengal

-Improving access to healthcare facilities like diagnostic test etc

-TN and Rajasthan health financing strategies

11

Reducing the medical economic burden of health insurance in China: Achievements and challenges

Dou, G. S

2018

China

Policy Forum

–

-Establish a mandatory social insurance program for urban employees

-Establish the New Rural Cooperative Medical Scheme (NCMS)

-Establish Urban Resident Basic Medical Insurance (URBMI) for Children, students, the elderly, the disabled, and other unemployed populations in urban regions groups not covered by basic health insurance

-Increase government subsidies to NCMS and URBMI to an unprecedented scale

-Launch Catastrophic Disease Insurance

-Replace FFS with other forms of prospective payment (prospective payment systems such as the global budget payment system

-DRG payments

-Increase the efficiency and quality of care under current payment systems

12

Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: do Indian households face distress health financing?

Anshul Kastor

2018

India

Research Article

3,33,104 individuals from 65,932 households (36,480 rural and 29,452 urban households)

-The Ministry of Health and Family Welfare, Government of India launched the National Program for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke

-Suggest for including treatment of cancer, heart diseases, and other rare and incurable diseases in the ambit of the health insurance coverage

-Provide free treatment to the vulnerable segment of the population for the treatment of cancer and heart diseases

-The coverage and the insurance amount of the RSBY need to be enlarged

13

Does public health system provide adequate financial risk protection to its clients? Out of pocket expenditure on inpatient care at secondary level public health institutions: causes and determinants in an eastern Indian state

Rout, S. K

2018

India

Research Article

239 inpatients

-Health system should ensure supply of essential medicines and create patient transport system in remote locations to reduce OOPE

14

The impact of out-of-pocket payments for dental care on household finances in low and middle income countries

Eduardo Bernabé

2017

London

Research Article

40 low and middle income countries

(1,74,257 adults, aged 18 years and above)

-Inclusion of dental care coverage in health insurance packages

-Integrating the prevention and control of oral diseases into universal health insurance coverage programs

15

Predictors of high out-of-pocket healthcare expenditure: an analysis using Bangladesh household income and expenditure survey, 2010

Azaher Ali Molla

2017

Bangladesh

Research Article

640 rural and 360 urban

households

-Providing a safety net for low-income rural households and for elderly members

-Control and prevention of chronic diseases

-Universal coverage of healthcare

-Launching some new types of safety net for the poor, the disabled and women

-Exemption process of fees for the poor, disabled and disadvantaged

16

Paying for Prescription Drugs Around the World: Why Is the U.S. an Outlier?

Dana O. Sarnak

2017

U.S

Issue Brief

Pharmaceutical spending in high-income, industrialized countries

-Control strategies drug price

-Employ centralized price, negotiations, national formularies, and comparative and cost-effectiveness research for determining price ceilings

-Federal government should negotiate lower drug prices for Medicare beneficiaries

-Universal health coverage

17

What Strategies Do Physicians and Patients Discuss to Reduce Out-of-Pocket Costs? Analysis of Cost-Saving Strategies in 1755 Outpatient Clinic Visits

Wynn G. Hunter

2016

America

Original Article

Patients with breast cancer, depression, rheumatoid arthritis visiting oncologists, psychiatrists, and rheumatologist

Strategies Involving Care-Plan Changes

 Changing to lower-cost alternative intervention

 Switching to generic form of intervention

 Changing dosage/frequency of intervention

 Stopping or withholding intervention

Strategies not involving care-plan changes

 Changing logistics of care

 Facilitating co-pay assistance or coupons

 Providing free samples

 Changing or adding insurance plans

18

Can health insurance protect against outof-pocket and catastrophic expenditures and also support poverty reduction? Evidence from Ghana’s National Health Insurance Scheme

Genevieve Cecilia Aryeetey

2016

Ghana

Original

3000 households

-Enrolment into health insurance reduced household costs

-Protective effect of the NHIS

-Reduce informal fees

19

The financial burden of out-of-pocket expenses in the United States and Canada: How different is the United States?

Katherine E Baird

2016

Canada

Original Article

2,03,799

United States

60,313

Canada

Households

-Expansion in insurance levels

-The ACA’s to match the actuarial value of insurance to income, and to place more stringent limits

20

The Parity Paradigm: Can Legislation Help Reduce the Cost Burden of Oral Anticancer Medications?

Sheetal M. Kircher

2016

Chicago

Policy Perspective

–

-Innovation in drug pricing to include value, introduction of performance-based payment, and a shift from coverage based on the route of administration

21

Women Saw Large Decrease In Out-Of-Pocket Spending For Contraceptives After ACA Mandate Removed Cost Sharing

Becker, N. V

2015

United States

Original

Women ages 13–45 who were enrolled in private health insurance

ACA-mandated removal of consumer cost sharing for prescription contraceptives (pill and IUD) in non grandfathered insurance plans

22

Payment reform pilot in Beijing hospitals reduced expenditures and out-of-pocket payments per admission

Jian, W

2015

Beijing

Original

Shifting payment of 108 diagnoses or procedures from FFS payment to a DRG at six tertiary general hospitals

-Broadly implement DRGs and refine payment systems

23

Changes in out-of-pocket payments for contraception by privately insured women during implementation of the federal contraceptive coverage requiremen

Lawrence B. Finer

2014

America

Original research article

3207 women aged 18–39 years

-Federal coverage in eliminating out-of-pocket costs among privately insured women for at least some methods of contraception

-Improve private health plans

-Choose a brand-name drug with a generic equivalent

-A need for federal and state policymakers to reexamine how the cost sharing protections for contraception under Medicaid are being applied by state agencies and Medicaid managed care plans

-Subsidized care provided by publicly supported health centers, such as health departments, Planned Parenthood clinics and community health centers, to low-income clients

24

Understanding Patient Options, Utilization Patterns, and Burdens Associated with Breast Cancer Screening

Harvey, S. C

2014

America

–

–

-Breast cancer screening (patient recall for further diagnostic imaging or procedures)

-Free breast cancer screening

25

Specialty Drug Coupons Lower Out-Of-Pocket Costs And May Improve Adherence At The Risk Of Increasing Premiums

Starner, C. I

2014

United States

Original

2,64,801

pharmacy’s prescriptions

-Drug coupons for multiple sclerosis or biologic anti-inflammatory drugs

26

Health-Related Financial Catastrophe, Inequality and Chronic Illness in Bangladesh

Md. Mizanur Rahman1

2013

Bangladesh

Original Article

Urban areas of Rajshahi

1593 households

-Implementing compulsory health insurance for salaried workers in both public and private sectors, and voluntary memberships for dependents, farmers and self-employed persons

-Improving routine management of NCDs, to reduce the cost of chronic disease management, and incorporating chronic disease management into public services and health financing initiatives, to ensure that this expenditure is included in risk pooling and welfare initiatives and the high OOP payments associated with chronic illness

-Incorporating ancillary services into basic care packages in public facilities

27

The impact of health insurance programs on out-of-pocket expenditures in Indonesia: an increase or a decrease?

Budi Aji

2013

Indonesia

Original Article

Indonesia Family Life Survey (IFLS) dataset

covering 7224 households

This study showed that two large existing health insurance programs in Indonesia, Askeskin and Askes. The ability of programs to offer financial protection by reducing out-of-pocket expenditures is likely to be a direct function of their benefits package and co-payment policies

28

The health care system reform in China: eects on out-of-pocket expenses and saving

Atella, V

2013

China

Original Article

Individuals and households from 11 provinces and municipalities from Household Income Project surveys

-The third stage of the health care system reform, Basic Insurance Scheme (BIS). (The program is financed by premium contributions from employers and employees. Retired workers are exempt from premium contributions and the cost of their contributions is to be borne by their former employers. his program expands coverage to private enterprises and smaller public enterprises. Moreover, self-employed workers are allowed to enter the program.)

-Public and private insurance prove to serve as a cushion against health risks

29

Practical aspects of telehealth: financial considerations

Loh, P. K

2013

Australia

Original

–

-Telehealth (online video consultation) save travel time for patients, careers and specialists, and can reduce out-of-pocket expenses

30

Out-of-pocket medical expenses for inpatient care among beneficiaries of the National Health Insurance Program in the Philippines

Tobe, M

2013

Philippines

Original

94,531 insurance claims

-Ensuring more investment for health from social health insurance and/or tax-based government funding, as well as shifting the provider payment mechanism from a fee-for-service to a case-based payment method, is essential

-NHIP (National Health Insurance Program in the Philippines)

31

Community pharmacy-based medication therapy management services: financial impact for patients

Dodson, S. E

2012

America

Original Research

Medicare Part D members who had been previously identified as eligible for MTM services

(128 patients)

-Patient participation in MTM services

(Medication Therapy Management)

32

Impact of healthcare reforms on out-of-pocket health expenditures in Turkey for public insurees

Erus, B

2012

Turkey

Original Paper

Household Budget Survey

-Inclusion of private providers in the system

-Decrease and even eliminate the co-payments for those at low-income levels

-Clear the system from informal payments

33

Individual Insurance Benefits To Be Available Under Health Reform Would Have Cut Out-Of-Pocket Spending In 2001–08

Hill, S. C

2012

Rockville, Maryland

Original

Adults ages 26–64 with individual insurance, insurance through small employers, insurance through large employers

-Adults individual insurance reduce risk for high out-of-pocket spending and lower average out of-pocket costs for medical care and prescription drugs

34

Insured yet vulnerable: out-of-pocket payments and India's poor

Shahrawat, R

2012

India

Original

1,24,644 (45 346 urban and 79,298 rural) households

-No OOP payments for drugs, for inpatient and for outpatient visits—on impoverishment

-Need to expand program benefits beyond inpatient care

-Insurance schemes like the RSBY which focus on the poor are an important new initiative to reduce the impoverishing effects of OOP payment for health

-Insurance schemes targeting the poor need to have a sufficiently wide coverage

35

Promoting Access and Reducing Expected Out-of-Pocket Prescription Drug Costs for Vulnerable Medicare Beneficiaries

Timothy W. Cutler

2011

California

Brief Report

Vulnerable Medicare beneficiaries

-Vulnerable Medicare beneficiaries should receive assistance from pharmacists and trained pharmacy students and enroll in the lowest-cost plans

-The Medicare Part D benefits

36

Effect of a medical subsidy on health service utilization among schoolchildren: A community-based natural experiment in Japan

Miyawaki, A

2010

Japan

Original

Children who were in grades 1–6

-Medical subsidy for children (MSC)

-Universal health coverage; this is achieved through public health insurance

37

Reducing out-of-pocket expenditures to reduce poverty: a disaggregated analysis at rural–urban and state level in India

Garg, C. C

2009

India

Comparative Study

1,20,000 household

-Rationalized drug policies (including free supplies)

-Pro-poor health financing policy focusing on financial protection not only for those close to the poverty line, but also those who are already below it in both rural and urban areas; and innovative financing mechanisms on the collection, pooling and purchasing side to reduce the intensity of poverty

-National Rural Health Mission (NRHM) provide quality health care to every household through its upgraded health infrastructure and provision of round the-clock health services

38

State Variations In The Out-OfPocket Spending Burden For Outpatient Mental Health Treatment

Zuvekas, S. H

2009

America

Original

Using data from the Medical Expenditure Panel Survey (MEPS)

-Consideration of policies related to the medications that account for two thirds of out-of-pocket spending

-Manage costly medications through policies such as tiered and restrictive formularies, increased cost sharing, step therapy, and prior authorization

-Encourage the use of effective generic medications, in place of expensive brand name medications

39

Health care-seeking behaviour and out-of-pocket payments in Tbilisi, Georgia

Gotsadze, G

2005

Georgia

Original

2500 households

Prioritize public financing of services for the poor, in particular through amending the Basic Benefit Package so that it better reflects the needs of the poor;

-Promote the quality and utilization of primary care services;

-Address the issue of rational drug use;

-Consider mobilizing out-of-pocket payments on a pre-paid basis through formal or community based risk pooling schemes

40

Physician Strategies to Reduce Patients’ Out-of-pocket Prescription Costs

Alexander, G. C

2005

United States

Original Investigation

700 General internists and 700 cardiologists from the American Medical Association

-Physicians should develop the habit of using brief just-in-time interventions at the point of prescription ordering

-Physicians should develop the habit of using brief just-in-time interventions at the point of prescription ordering

-Switch from a brand-name to a generic drug

-Give the patient office samples

-Critically review medication list and discontinue nonessential medicines

-Switch to a different brand-name drug within the same drug class

-Prescribe a higher dose of medicine and tell the patient to split the tablets

-Refer the patient to a pharmaceutical company assistance program

-Recommend the use of an over-the-counter medicine as a substitute

-Refer the patient to a public aid agency or social worker