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Out-of-Pocket Healthcare Expenditure Burdens Among Nonelderly Adults With Hypertension
Didem Minbay Bernard, PhD; Patrik Johansson, MD, MPH; and Zhengyi Fang, MS
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Out-of-Pocket Healthcare Expenditure Burdens Among Nonelderly Adults With Hypertension

Didem Minbay Bernard, PhD; Patrik Johansson, MD, MPH; and Zhengyi Fang, MS
Among nonelderly adults receiving hypertension treatment, 13.1% had high burdens, meaning that healthcare expenditures accounted for more than 20% of their income.
The first 3 rows in Table 1 show that risk of high total burdens was significantly greater for persons receiving treatment for hypertension compared with other chronically ill patients and well patients. Among patients who received hypertension treatment, 13.1% had high total burdens in contrast to 10.5% among those with other chronic conditions and 5.3% among those without chronic conditions. Cancer, diabetes, and heart disease are other chronic conditions that lead to similarly high burdens.21,22,24

Burdens by Insurance Status Among Patients With Hypertension Treatment

The average annual population of persons receiving treatment for hypertension was 30.3 million between the years 2007 and 2009. Among nonelderly adults who received hypertension treatment, 71.1% had private group coverage (21.6 million), 2.6% had private non-group coverage (0.8 million), 15.5% had public coverage (4.7 million), and 10.8% were uninsured (3.3 million).

Focusing on healthcare burdens, Table 1 shows that the uninsured and those with public coverage were the most likely to have high burdens (20.0% and 16.8%, respectively). However, in terms of total burdens, those with private non-group insurance were the most likely to have high burdens (49.9%), followed by the uninsured (21.0%), those with public insurance (18.6%), and those with private group insurance (9.3%).

Among nonelderly adults who received hypertension treatment, older age, being female, never married or widowed, having no children, not working, working parttime, not having high income (being poor, near poor/ low income, or middle income), lower education (high school or less), living in non-metropolitan statistical areas (MSAs), living anywhere except the Northeast, and having other chronic conditions were associated with high total burdens (eAppendix, Table 1).

Out-of-Pocket Expenditures by Service Type

Table 2 presents person-level spending on hypertension treatment versus other conditions among nonelderly adults who were receiving treatment for hypertension. Among all nonelderly adults who received hypertension treatment, the mean of total out-of-pocket expenditure on healthcare was $1163. Mean out-of-pocket expenditure on healthcare was highest among those with private nongroup insurance ($1796), followed by the uninsured ($1555), those with private group insurance ($1139), and those with public insurance ($897). Out-of-pocket expenditures for hypertension treatment (including all types of services for hypertension treatment) accounted for 15% of total outof- pocket expenditures on healthcare among those with treated hypertension.

Mean out-of-pocket expenditures on all prescription drugs (for the treatment of hypertension and other conditions) was $535. Prescription drugs for hypertension treatment accounted for 25% of total out-of-pocket expenditure on prescription drugs for those who received hypertension treatment.

Self-Perceived Financial Barriers to Care Among Adults Receiving Treatment for Hypertension

Table 3 shows that among those with high total burdens, 15.7% were unable to get care and 13.6% had to delay care during the past year due to financial reasons. Among those without high total burdens, 8.4% were unable to get care and 7.6% had to delay care during the past year due to financial reasons.

Focusing on those with high total burdens, 23.9% among those with public coverage and 35.2% among the uninsured said they were unable to get care due to financial reasons. Among those who said they were unable to get care due to financial reason, 85.3% of those with public coverage and 91.4% among the uninsured said that going without care was a big problem.

Burdens Among Adults With Hypertension Who Are Not Actively in Treatment

We found that burdens among persons who reported having hypertension in the current year but who were not actively in treatment (ie, those who chose not to get treatment for hypertension) were not significantly different statistically from those who were treated for hypertension (6.2% [0.8] and 7.1% [0.3], respectively). Furthermore, among adults with hypertension, we found that average income was significantly lower among those who were not actively in treatment compared with adults who received treatment for hypertension ($42,942 and $50,810, respectively).

DISCUSSION

Among nonelderly adults who received hypertension treatment, those with private non-group insurance were the most likely to have high burdens (49.9%), followed by the uninsured (21.0%), those with public insurance (18.6%), and those with private group insurance (9.3%). Furthermore, among adults with hypertension, we found that average income was significantly lower among those who were not actively in treatment compared with adults who received treatment for hypertension ($42,942 vs $50,810, respectively). Many antihypertensive medications are available in generic form, which has led to more affordable therapies. Despite the availability of more affordable therapies, our results suggest that cost of treatment still may be a factor in the decision by some adults to go without treatment.

Furthermore, we found that a significant proportion of those with high total burdens said they were unable to get care (15.7%) or said they had to delay care (13.6%) due to financial reasons. For persons with high total burdens, 23.9% among those with public coverage and 35.2% among the uninsured said they were unable to get care due to financial reasons.

We also found that the prevalence of high burdens is significantly higher among those who had treatment for at least 1 other chronic condition in addition to hypertension treatment (8.2% vs 14.2%). In our sample, 78% of adults who received hypertension treatment also had treatment for at least 1 other chronic condition. Among patients with hypertension who had at least 1 other chronic condition, 44% had hyperlipidemia, 23% had diabetes, 24% had mental disorders, and 14% had heart disease. These findings highlight the importance of taking into account all health-related expenditures in examining out-of-pocket burdens rather than just condition-specific treatment costs.

In terms of study limitations, note that our goal was to examine the prevalence of high burdens among persons with hypertension. It is beyond the scope of this study to disentangle the multiple potential causal relationships among health conditions, income (which can be reduced due to illness), insurance coverage, and healthcare expenditures, and we do not attempt to do so. Second, we cannot examine the variation in burdens either by treatment type, due to sample size limitations, or by stage of illness, because it is not reported in MEPS. Third, examining the variation in burdens by level of treatment adherence is beyond the scope of this study. Fourth, our findings on financial barriers are self-reported. We cannot tell if patients who “choose” to not get care sometimes use cost as an excuse, when the real reason may be lack of motivation, not wanting to take medication, not understanding the importance of care, or other reasons. This is why the primary focus of our study was the actual burden measure (ie, the ratio of health-related expenditures to family income).

The increased prevalence of hypertension risk factors in the United States, in the form of an obesity epidemic and an aging population, underscores the importance of continued hypertension management and control. With the implementation of the Affordable Care Act (ACA), nonelderly adults with hypertension who are currently uninsured or have private non-group insurance will gain access to affordable coverage through the exchanges. Furthermore, the ACA sets limits on out-of-pocket spending for deductibles, coinsurance, and copayments. For the plan year beginning in 2014, the annual out-of-pocket maximums are $6350 for an individual and $12,700 for a family. Coverage through the exchanges and caps on outof- pocket spending are likely to reduce the prevalence of high burdens among adults with hypertension.

Hypertension represents the most common reason for office visits to primary care physicians.32-34 However, recent studies show that 80% of physicians are unaware of medication costs and also misunderstand the complexities of insurance coverage.35,36 Thus, raising awareness among providers regarding the prevalence of high out-of-pocket burdens and self-perceived financial barriers to care may encourage providers to discuss healthcare coverage and associated costs with their patients. To the extent that patients’ perceptions about their ability to pay are incorrect, physicians can change those perceptions. Furthermore, health plans could reduce patient cost sharing on drugs for which there is a strong body of evidence documenting cost-saving treatment such as antihypertensive medication. Addressing financial barriers to care may improve treatment adherence among patients with hypertension.

Author Affiliations: Agency for Healthcare Research and Quality— Center for Financing, Access and Cost Trends, Rockville, MD (DMB); University of Nebraska Medical Center, College of Public Health, Omaha, NE (PJ); Social & Scientific Systems, Silver Spring, MD (ZF).

Source of Funding: None reported.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (DMB, PJ); acquisition of data (DMB, ZF); analysis and interpretation of data (DMB, PJ, ZF); drafting of the manuscript (DMB, PJ); critical revision of the manuscript for important intellectual content (DMB); statistical analysis (ZF).

Address correspondence to: Didem Minbay Bernard, Agency for Healthcare Research and Quality, 540 Gaither Rd, Rockville, MD 20850. E-mail: Didem.Bernard@ahrq.hhs.gov.
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