Rising healthcare expenses in developed nations have made it difficult for many people to seek the medical care they need. From 2011 to 2012, healthcare costs in the United States increased 3.7 percent, costing consumers $2.8 trillion, or $8,915 each person. Some analysts estimated the latest figures to be closer to $3.8 trillion with government spending at a whopping 17.9% of GDP.
Australians spent $132.4 billion on healthcare, while people in the UK spent £24.85 billion. Government expenditure in both these countries sit at between 9-10% of GDP, which may seem more manageable compared to the US, however healthcare leaders in both these countries are taking a firm view of preventing any escalation of these percentages.
With the high costs of health care around the world, many stakeholders wonder if introducing or adjusting copayments will produce better health outcomes.
The topic is being hotly debated in Australia, where co-payments for General Practitioner visits have been proposed by the Liberal government in its most recent Federal Budget announcement. However, while healthcare stakeholders seem obsessed with costs, the question is do copayments actually improve health outcomes for these nations?
Copayments and Health Outcomes: Is There a Correlation?
Researchers have studied the effects copayments have on health outcomes for many years. The RAND experiment was conducted in the 1970s, but a recent report was prepared for the Kaiser Family Foundation. Jonathan Gruber, Ph.D., from Massachusetts Institute of Technology, examined the RAND experiment and brought to light that high copayments may reduce public health care utilisation, but may not affect their health outcomes. The study followed a broad cross section of people who were rich, poor, sick, healthy, adults, and children.
In a 2010 study published in The New England Journal of Medicine, researchers found the opposite was true for senior citizens. Those that had higher copayments reduced their number of doctor visits. This worsened their illnesses, which resulted in costly hospital care. This was especially true for those who had a low income, lower education, and chronic disease.
Whilst intuitively we may feel that copayments in healthcare may make us value our own health more, these two studies signal that this is not necessarily the case. In fact, higher copays can lead to additional healthcare costs to the health system due to indirectly increasing hospital stays for the elderly.
Those that are not senior citizens may be able to avoid hospital care because they don’t have a high medical risk and hence be less adversely affected by such copayments. In making any conclusions about introducing copayment, we could also take learnings from the relationship of health outcomes and which is another consideration when studying the effects of copayments.
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Copayments for Medication: Does It Affect Medication Adherence and Health Outcomes?
A study funded by the Commonwealth Fund, found that when US based insurance company Pitney Bowes eliminated copayments for people with diabetes and vascular disease, medication adherence improved by 2.8%. Another study examining the effects of reducing or eliminating medication copayments found that adherence increased by 3.8% for people taking medications for diabetes, high blood pressure, high cholesterol, and congestive heart failure.
Considering medication adherence is important when trying to determine if copayments affect health outcomes. When people take medications as prescribed to prevent or treat illness and disease, they have better health outcomes. A literature review published in the U.S. National Institutes of Health’s National Library of Medicine (MIH/NLM) explains that many patients with high cost sharing ended up with a decline in medication adherence, and in turn, poorer health outcomes.
The correlation of medication adherence and health outcomes is found in other parts of the world as well. According to the Australian Prescriber, increasing copayments affects patients who have a low income and chronic medical conditions requiring multiple medications. When they can’t afford their medications, they either reduce or stop many of their medications, which can lead to serious health problems. These patients then need more doctor visits and in severe cases, hospital care.
Medication copayments effects on health outcomes were also found in a Post-Myocardial Infarction Free Rx Event and Economic Evaluation (MI FREEE) trial. Nonwhite heart attack patients were more likely to take their medications following a heart attack if copayments were eliminated, which decreased their readmission rates significantly.
Health Outcomes Based on Medication vs. Medical Care?
Is it possible that expensive copayments may only affect health outcomes for people who are on multiple medications? The research seems to reflect that may be the case. People seem to go to the doctor less when copayments are high, but it seems that senior citizens are the ones that end up suffering the poorer health outcomes due to the lack of regular medical supervision and possibly poor medication adherence. The decreased medication adherence seems to have the biggest effect on health outcomes, especially when the prescription drugs are for the treatment of an illness or disease. It seems as though the elderly and people needing multiple medications will benefit the most from lower copayments in terms of better health outcomes.
Should copayments for visiting doctors be introduced in countries like Australia?
My thoughts are therefore, if copayments are going to be introduced for visiting a doctor, we should provide exemptions for those that cannot afford it, e.g. senior citizens and pensioners. We also need to look at putting a cap on copayments, so that those with chronic conditions genuinely requiring multiple medical visits are not ridiculously out-of-pocket.
Human nature is such that when we receive something for free, it is often not valued appropriately. I do think that placing a nominal price on our healthcare is a good thing in Australia, as I do believe that the vast majority of people will appreciate the generally good quality of care we receive in this country.
Copayments are appropriate for those that can afford it, and should not be at the expense of those who cannot. This supports the premise of egalitarian healthcare systems that Australia aspires to continue.
Here is where we need to be careful about how we debate the issue, and not place the issue in one generalised basket. I am very much in favour of healthcare system that is adaptive and customised to individual needs, and this is what we should aspire to do in our discussions about copayments.
What do you think?