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