Health benefit utilization and out-of-pocket expenses in outpatient care and hospitalizations: Baseline surveys of three primary care sites in the Philippines

Background@#The Philippine Primary Care Studies (PPCS) is a network of pilot studies that developed, implemented, and tested strategies to strengthen primary care in the country. These pilot studies were implemented in an urban, rural, and remote setting. The aim is to use the findings to guide the policies of the national health insurance program (PhilHealth), the main payor for individualized healthcare services in the country.@*Objective@#The objective of this report is to compare baseline outpatient benefit utilization, hospitalization, and health spending, including out-of-pocket (OOP) expenses, in three health settings (urban, rural, and remote). These findings were used to contextualize strategies to strengthen primary care in these three settings.@*Methods@#Cross-sectional surveys were carried out using an interviewer-assisted questionnaire on a random sample of families in the urban site, and a stratified random sample of households in the rural and remote sites. The questionnaire asked for out-patient and hospitalization utilization and spending, including the OOP expenses. @*Results@#A total of 787 families/households were sampled across the three sites. For outpatient benefits, utilization was low in all sites. The remote site had the lowest utilization at only 15%. Unexpectedly, the average annual OOP expenses for outpatient consults in the remote site was PhP 571.92/per capita. This is 40% higher than expenses shouldered by families in the rural area, but similar with the urban site. For hospital benefits, utilization was lowest in the remote site (55.7%) compared to 75.0% and 78.1% for the urban and rural sites, respectively. OOP expenses per year were highest in the remote site at PhP 2204.44 per capita, probably because of delay in access to healthcare and consequently more severe conditions. Surprisingly, annual expenses per year for families in the rural sites (PhP 672.03 per capita) were less than half of what families in the urban sites spent (PhP 1783.38 per capita). @*Conclusions@#Compared to families in the urban site and households in the rural sites, households in remote areas have higher disease rates and consequently, increased need for outpatient and inpatient health services. When they do get sick, access to care is more difficult. This leads to lower rates of benefit utilization and higher out-of-pocket expenses. Thus, provision of “equal” benefits can inadvertently lead to “inequitable” healthcare, pushing disadvantaged populations into a greater disadvantage. These results imply that health benefits need to be allocated according to need. Families in poorer and more remote areas may require greater subsidies.

Telehealth and Outpatient Visits Among Individuals with Chronic Conditions by Socioeconomic Status in the First Year of the COVID-19 Pandemic: Observational Cohort Study.

Objective: We investigated telehealth usage for individuals with chronic conditions by neighborhood-level socioeconomic status (SES) during the first year of the COVID-19 pandemic. Methods: We split the population of 2.3 million commercially insured adults in the United States with at least one chronic condition in claims into four quartiles of SES using address of residence. After balancing groups on baseline characteristics, we examined telehealth and total outpatient evaluation and management (E&M) visits from March 2020 to February 2021. Results: Quartile 4 (highest SES) had more telehealth visits per person (0.054-0.100 more visits over each 3-month period) and a higher percentage of visits that were telehealth (1.8-5.9 percentage points higher) than other quartiles. Quartile 4 had higher levels of total outpatient E&M use throughout the year. Differences in telehealth between Quartiles 1 and 3 were small. Conclusions: Commercially insured individuals in the highest SES quartile had higher use of telehealth and total E&M visits than other quartiles.

Configuration and Delivery of Primary Care in Rural and Urban Settings.

BACKGROUND: There are concerns about the capacity of rural primary care due to potential workforce shortages and patients with disproportionately more clinical and socioeconomic risks. Little research examines the configuration and delivery of primary care along the spectrum of rurality. OBJECTIVE: Compare structure, capabilities, and payment reform participation of isolated, small town, micropolitan, and metropolitan physician practices, and the characteristics and utilization of their Medicare beneficiaries. DESIGN: Observational study of practices defined using IQVIA OneKey, 2017 Medicare claims, and, for a subset, the National Survey of Healthcare Organizations and Systems (response rate=47%). PARTICIPANTS: A total of 27,716,967 beneficiaries with qualifying visits who were assigned to practices. MAIN MEASURES: We characterized practices' structure, capabilities, and payment reform participation and measured beneficiary utilization by rurality. KEY RESULTS: Rural practices were smaller, more primary care dominant, and system-owned, and had more beneficiaries per practice. Beneficiaries in rural practices were more likely to be from high-poverty areas and disabled. There were few differences in patterns of outpatient utilization and practices' care delivery capabilities. Isolated and micropolitan practices reported less engagement in quality-focused payment programs than metropolitan practices. Beneficiaries cared for in more rural settings received fewer recommended mammograms and had higher overall and condition-specific readmissions. Fewer beneficiaries with diabetes in rural practices had an eye exam. Most isolated rural beneficiaries traveled to more urban communities for care. CONCLUSIONS: While most isolated Medicare beneficiaries traveled to more urban practices for outpatient care, those receiving care in rural practices had similar outpatient and inpatient utilization to urban counterparts except for readmissions and quality metrics that rely on services outside of primary care. Rural practices reported similar care capabilities to urban practices, suggesting that despite differences in workforce and demographics, rural patterns of primary care delivery are comparable to urban.

[Analysis of outpatient utilization of pneumoconiosis patients in Jiangsu province].

Objective: To understand the situation and characteristics of out-patient utilization of urban and rural pneumoconiosis patients in Jiangsu province, and to provide a reference for the formulation of relevant policies. Methods: Using a questionnaire on patients with pneumoconiosis and their influencing factors, 120 patients with pneumoconiosis were randomly selected in Nanjing, Wuxi, Suzhou, Yancheng Vocational Defense Institute or CDC. The rate of outpatients with pneumoconiosis in urban and rural areas and the choice of out-patient hospitals were analyzed. Results: Of the 75 patients with severe pneumoconi-related symptoms such as chest tightness and dyspnea in the first two weeks of the survey, 36 (48.0%) lived in cities and 39 (52.0%) lived in rural areas. Patients with pneumoconiosis who live in urban and rural areas have different aggravating conditions within two weeks. Two weeks of aggravated symptoms in outpatient consultations accounted for36 (48.0%) . Of the 36 patients who used outpatient treatment, rural residents mainly chose 8 people from a hospital and a township health hospital, accounting for 34.8%, while 10 people from urban residents chose a nursing home or nursing home, accounting for 40.0%. The main reason why urban and rural pneumoconiosis patients did not go to the doctor is "conscious symptoms are lighter" and "feel that the doctor is useless." Conclusion: The rate of outpatients with pneumoconiosis in Jiangsu province within two weeks is lower than that of ordinary elderly residents. There may be differences in treatment behavior patterns of urban and rural pneumoconiosis patients.Economic factors have a certain influence on the outpatient treatment behavior of pneumoconiosis patients. The recognition of outpatient service is the main factor affecting the outpatient treatment of pneumoconiosis patients. It is very important to popularize the knowledge of pneumoconiosis and do a good job in propaganda of occupational diseases and health education for pneumoconiosis patients. Focusing on the outpatient treatment of pneumoconiosis patients and making targeted medical policies is very important to standardize and improve the rehabilitation of pneumoconiosis patients.

Analysis of outpatient utilization of pneumoconiosis patients in Jiangsu province / 中华劳动卫生职业病杂志

Objective@#To understand the situation and characteristics of out-patient utilization of urban and rural pneumoconiosis patients in Jiangsu province, and to provide a reference for the formulation of relevant policies.@*Methods@#Using a questionnaire on patients with pneumoconiosis and their influencing factors, 120 patients with pneumoconiosis were randomly selected in Nanjing, Wuxi, Suzhou, Yancheng Vocational Defense Institute or CDC. The rate of outpatients with pneumoconiosis in urban and rural areas and the choice of out-patient hospitals were analyzed.@*Results@#Of the 75 patients with severe pneumoconi-related symptoms such as chest tightness and dyspnea in the first two weeks of the survey, 36 (48.0%) lived in cities and 39 (52.0%) lived in rural areas. Patients with pneumoconiosis who live in urban and rural areas have different aggravating conditions within two weeks. Two weeks of aggravated symptoms in outpatient consultations accounted for36 (48.0%) . Of the 36 patients who used outpatient treatment, rural residents mainly chose 8 people from a hospital and a township health hospital, accounting for 34.8%, while 10 people from urban residents chose a nursing home or nursing home, accounting for 40.0%. The main reason why urban and rural pneumoconiosis patients did not go to the doctor is "conscious symptoms are lighter" and "feel that the doctor is useless."@*Conclusion@#The rate of outpatients with pneumoconiosis in Jiangsu province within two weeks is lower than that of ordinary elderly residents. There may be differences in treatment behavior patterns of urban and rural pneumoconiosis patients.Economic factors have a certain influence on the outpatient treatment behavior of pneumoconiosis patients. The recognition of outpatient service is the main factor affecting the outpatient treatment of pneumoconiosis patients. It is very important to popularize the knowledge of pneumoconiosis and do a good job in propaganda of occupational diseases and health education for pneumoconiosis patients. Focusing on the outpatient treatment of pneumoconiosis patients and making targeted medical policies is very important to standardize and improve the rehabilitation of pneumoconiosis patients.

Insurance coverage and socioeconomic differences in patient choice between private and public health care providers in China.

The private health care sector has become an increasingly important complement to China's health care system. During the health care reform in 2009, China's central government established multiple initiatives to relax constraints on the growth of the private health care sector. However, private health services have not been growing as rapidly as private health care facilities. Using data from the China Health and Retirement Longitudinal Study collected between 2011 and 2013, this study investigated patient choice between private and public providers for outpatient care and estimated its relationship with health insurance and socioeconomic status (SES). The Heckman sample selection model was applied to address the problem of selection bias caused by a lack of awareness of provider ownership. We found that 82.1% of the outpatient care users were aware of their provider's ownership, and 23.8% chose private health care providers. Although patients with health insurance and higher SES were more likely to be aware of their provider's ownership, they preferred public providers over private providers. For example, having Urban Employee Basic Medical Insurance was associated with a 16.5% lower probability of choosing private providers than no health insurance. Respondents with the highest level of household expenditure had a 7.5% lower probability of choosing private providers than those with the lowest level of expenditure. The probability of choosing private providers were significantly lower by 4.0% among respondents with an education level of junior high school and above than those with no formal education. For private providers to play an effective role in the health care system, policies that have constrained the growth of the private sector should be changed, and more effort should be directed toward equalizing health insurance coverage for both types of providers.

Medical Savings Account balance and outpatient utilization: Evidence from Guangzhou, China.

Medical Savings Account (MSA) is a financing instrument designed to reduce consumer-side moral hazards. The Urban Employee Basic Medical Insurance (UEBMI) scheme in China has an MSA component in addition to a Social Risk-pooling Fund. This study examines the association between MSA balance and outpatient utilization in Guangzhou, China, and determines MSA's impact on utilization under different circumstances. It also seeks to ascertain whether MSA has achieved its intended functions of "Cost-containment", "Saving for the future" and "Enabling utilization". The first group of 114,657 MSA account-holders, including both employees and retirees, who consistently insured with UEBMI from 2002 to 2007, are selected for this study. A two-part model is employed to estimate the effect of the MSA balance on the probability of outpatient services utilization and on the level of outpatient expenditure. Results show that MSA balance is significantly associated with the likelihood of using outpatient services as well as the level of outpatient expenditure. The association is a non-linear U-shaped relationship for working individuals, and an inverted U-shaped relationship for the retirees. The observed U-shaped relationship for working individuals implies that at lower MSA balance levels, a negative balance-expenditure relation exits, while at higher MSA balance levels, the relationship is positive--suggesting possible improper utilization when MSA balance reaches high levels. Setting a maximum MSA balance limit and/or allowing enrollees to use MSA funds to purchase private insurance appears to be desirable. The observed inverted U-shaped relationship for retirees suggests that many retirees have to spend whatever funds they have in their MSA for outpatient care, but the less healthy individuals are able to shift the spending to inpatient care which is mainly financed by the Social Risk-pooling Fund. The results of this study also affirm the usefulness of MSA in performing its intended functions.