Out-of-Pocket Healthcare Expenditure Burdens Among Nonelderly Adults With Hypertension | Page 2
Published Online: May 21, 2014
Didem Minbay Bernard, PhD; Patrik Johansson, MD, MPH; and Zhengyi Fang, MS
The pooled MEPS-HC sample includes 9383 persons who received hypertension treatment, 17,404 persons with other chronic conditions, and 47,650 persons with no chronic conditions. We also examined burdens among persons who reported that they have hypertension in the current year but were not actively in treatment (ie, those who chose not to get treatment for hypertension).
Each person is classified as having private group (employment- related) insurance, private non-group (individual) insurance, public insurance, or no coverage. Persons with no private or public coverage anytime during the year were classified as having no coverage. We distinguished between 2 types of private insurance because non-group insurance is generally more expensive and provides less generous benefits.31
Out-of-pocket premiums were collected from household respondents for private group coverage and private non-group coverage. All premium amounts were prorated to account for the duration of coverage during the year.
Expenditures were classified into 4 service categories: hospital stays, ambulatory visits (office-based provider and outpatient), prescription medications, and “all other” services (emergency department, home health visits, dental visits, and other). All expenditure amounts were converted using the Consumer Price Index for all urban consumers and reported in 2009 US dollars.
All estimates were weighted to represent the US civilian noninstitutionalized population. Standard errors were corrected to account for the complex design of MEPS, with Taylor series linearization of the variance. Only differences statistically significant at the 5% level were discussed in the text. For further details of the methodology, see eAppendix.
Burdens by Medical Condition
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).
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).
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