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
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

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).

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Issue: May 2014
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