Out-of-Pocket Healthcare Expenditure Burdens Among Nonelderly Adults With Hypertension

Published Online: May 21, 2014
Didem Minbay Bernard, PhD; Patrik Johansson, MD, MPH; and Zhengyi Fang, MS

To examine the prevalence of high out-of-pocket burdens and self-perceived financial barriers to care among patients receiving hypertension treatment.

Study Population

Persons 18 to 64 years receiving treatment for hypertension from a nationally representative sample of the US population from the 2007 to 2009 Medical Expenditure Panel Survey.

Main Outcome Measures

The proportion of persons living in families with high a out-ofpocket burden associated with medical spending relative to income, defining high healthcare burden as spending on healthcare greater than 20% of income and high total burden as spending on healthcare and insurance premiums greater than 20% of income.


The prevalence of high total burdens was significantly greater for persons receiving treatment for hypertension (13.1%) compared with other chronically ill (10.5%) and well patients (5.3%). Among hypertension patients with high total burdens, 15.7% said they were unable to get care and 13.6% said they delayed care due to financial reasons. Self-perceived financial barriers were highest among the uninsured and those with public coverage: 35.2% among the uninsured and 23.9% among those with public coverage said they were unable to get care due to financial reasons.


High burdens may deter patients from getting needed care. Our findings have 2 distinct policy implications. First, raising awareness among providers regarding the prevalence of high out-ofpocket burdens and financial barriers to care may encourage physicians 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 help patients overcome barriers to treatment. Second, 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.

Am J Manag Care. 2014;20(5):406-413
Affecting more than 65 million Americans and a leading modifiable risk factor for heart disease and stroke, hypertension represents a costly public health challenge in terms of mortality and healthcare expenditures.1 According to the World Health Organization, hypertension contributes to approximately two-thirds of cerebrovascular burdens and half of the coronary heart disease burdens in the world.2 In 2010, heart disease and stroke represented the first and third-leading causes of death in the United States.3 Total direct costs of cardiovascular disease care were $273 billion and indirect costs were $172 billion in 2010 (calculated in 2008 US dollars).4

Furthermore, disparities in hypertension prevalence exist between US racial and ethnic groups. While the 2009 to 2010 US prevalence of hypertension (adult, all races) equaled 28.6%, the non-Hispanic black population experienced a significantly higher prevalence of hypertension than the non-Hispanic white and Mexican American populations (age-adjusted rates of 40.4% vs 27.4% and 26.1%, respectively). 5 For these reasons, addressing the effective prevention, detection, treatment, and control of hypertension all remain essential goals of public health policy and initiatives such as Healthy People 2020, the nation’s list of 10-year objectives for improving the health of all Americans; the National High Blood Pressure Education Program of the National Institutes of Health; and the National Quality Strategy.6-8

A recent study estimated that benefit-to-cost ratio of antihypertensive therapy is 10:1 for men and 6:1 for women.9 Given the high societal return on investment for antihypertensive therapy, the question is why we do not do better at controlling hypertension. Medications that control hypertension have proven to reduce significantly the incidence of associated poor health outcomes such as renal failure, congestive heart failure, stroke, and ischemic heart disease, regardless of gender, age, ethnicity, or race10; however, in spite of improved control rates over recent years, the total number of patients with uncontrolled hypertension has increased.11,12 The importance of antihypertensive control through medical management is noted in Healthy People 2020’s Heart Disease and Stroke Objective 11.6 This objective seeks to increase the proportion of adults with hypertension who are taking a prescribed medicine to lower their blood pressure by 10%— from 63.2% during the period of 2005 through 2008 to 69.5% in 2020 (age-adjusted to the year 2000 standard population). National Center for Health Statistics data indicate that the proportion of people with hypertension who are treated has increased from 63.2% during the period of 2005 through 2008 to 76.4% during the period of 2009 through 2010.13,14 This trend is consistent with Healthy People 2020’s Heart Disease and Stroke Objective 11. But despite the increase in the proportion of people with hypertension who are being treated, studies indicate that approximately 50% of people who started on antihypertensive therapies discontinue their use within 6 to 12 months of initiation.14

Patient treatment adherence is influenced by a number of patient-related, provider-related, and healthcare delivery– related factors.15 Nonadherence can lead to higher long-term costs due to complications and avoidable hospitalizations. 11,16 Thus, it is important to identify factors that are associated with nonadherence.

One potential reason patients delay or go without needed care is a high out-of-pocket burden. Thus, it is important to examine health-related financial burdens among patients receiving treatment for chronic conditions such as hypertension. Many studies focus on expenditures for the treatment of hypertension only.17-21 Our study also considers the impact of total health-related expense, including the cost of hypertension treatment, for the individual and the family. We do this because delaying treatment or going without treatment altogether may be a result not only of hypertension-specific costs but of total health-related expenses both for the individual and the family. We examine healthcare burden relative to income, including expenditures on health insurance premiums in the total burden measure to provide a more accurate picture of health-related financial strain. The burden measure is the ratio of healthcare cost to income. In this measure, both healthcare cost and income can play a primary role. We do this because a given level of healthrelated expenditure is likely to be more burdensome for families with lower incomes. First, we examine the vartion in burdens among patients with hypertension treatment by insurance status and other sociodemographic characteristics. Second, we examine person-level spending on hypertension treatment versus other conditions. Third, we examine self-perceived financial barriers to care among patients receiving hypertension treatment.


The data are from the Medical Expenditure Panel Survey-Household Component (MEPS-HC), sponsored by the Agency for Healthcare Research & Quality (AHRQ). Every year, the MEPS-HC panel is selected from a sample of households among those that participated in the prior year’s National Health Interview Survey (NHIS). MEPSHC is a 2-year rotating panel of households designed to yield nationally representative estimates of healthcare expenditures for the civilian, noninstitutionalized population. Data are collected through 5 rounds of interviews and include medical expenditures, insurance coverage, premiums, and other socioeconomic characteristics.22

MEPS-HC is a rich data source for analyzing out-ofpocket burdens because it includes all payers and all components of expenditures, unlike claims data, which only include covered services. Because MEPS-HC is a household survey, the data collected are self-reported. However, MEPS also includes a Medical Provider Component (MPC) that requests data from hospitals, physicians, home healthcare providers, and pharmacies identified by MEPSHC respondents. The MEPS-MPC is designed to obtain information on both the medical and financial characteristics of medical events. Its purpose is to supplement and/ or replace information received from the MEPS-HC respondents about the healthcare that was provided to sampled household members in the course of the survey year.

For the burden analysis among patients receiving treatment for hypertension, we pooled MEPS-HC data for the period of 2007 to 2009 to obtain a large enough sample to make reliable estimates for population subgroups. The unit of observation is a person aged 18 to 64 years. The burden measure includes out-of-pocket expenditures for all healthcare services, because burdens may be greater than the cost of hypertension treatment. Healthcare burdens are constructed as the share of family-level after-tax income spent on health-related expenditures, because family members share financial resources. Family-level burdens are then assigned to individuals within the family and the results are presented at the person level, enabling us to quantify the number of persons who live in families with high burdens.

Following previous literature, high burden is defined as health-related spending in excess of 20% of income.23-28 Although there is no consensus on what constitutes affordable costs, similar patterns across subgroups result from using alternative thresholds such as 10% and 30%. Healthcare burden includes expenditures on all healthcare services such as deductibles, copays, cost sharing, and payments for services not covered by insurance plans. Total burden includes out-of-pocket expenditures on health insurance premiums in addition to out-of-pocket expenditures on healthcare services.

We also examined the impact of perceived financial barriers. The MEPS questionnaire asked respondents if they delayed care or were unable to get care, as well as the reason for delaying or going without care. If the respondent reported that (1) they could not afford care; or (2) insurance would not approve, cover, or pay; or (3) a doctor refused the family insurance plan, we coded that person as having reported financial barriers to care. The MEPS questionnaire also asked whether delaying or going without care was a big problem.

Medical conditions were collected verbatim from households and coded by professional coders using the International Classification of Diseases, Ninth Revision (ICD- 9). Condition categories were created using AHRQ’s Clinical Classification Software (CCS), which compiles ICD-9 codes into clinically meaningful categories.29 Our analysis was based on “treated prevalence” (ie, persons who reported medical treatment for hypertension any time during a year).

We classified persons into 3 mutually exclusive categories: (1) hypertension (persons with 1 or more medical events associated with CCS codes 98 and 99); (2) other chronic condition (persons with no medical events associated with hypertension, but who have 1 or more medical event associated with other chronic conditions); and (3) no chronic condition (persons with no medical events associated with any chronic conditions). Chronic conditions were defined based on the fully specified ICD-9-CM (Clinical Modification) diagnosis codes using the Healthcare Cost and Utilization Project’s (HCUP) Chronic Condition Indicator (CCI).30

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Issue: May 2014
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