Essential medicines for universal health coverage

Interrupted time series analysis in drug utilization research is increasing: systematic review and recommendations

Non-evidence-based policy: how effective is China's new cooperative medical scheme in reducing medical impoverishment?

Promotion of access to essential medicines for non-communicable diseases: practical implications of the UN political declaration.

Introduction Out-of-pocket payments create financial barriers that prevent millions of people each year from seeking and receiving needed health services (1,2) In addition, many of those who do seek and pay for health services are confronted with financial catastrophe and impoverishment (3-5) People who do not use health services at all, of who suffer financial catastrophe are the extreme Many others might forego only some services, or suffer less severe financial consequences imposed by user charges, but people everywhere, at all income levels, seek protection from the financial risks associated with ill health A question facing all countries is how their health financing systems can achieve or maintain universal coverage of health services Recognizing this, in 2005 the Member States of WHO adopted a resolution encouraging countries to develop health financing systems aimed at providing universal coverage (6) This was defined as securing access for all to appropriate promotive, preventive, curative and rehabilitative services at an affordable cost Thus, universal coverage incorporates two complementary dimensions in addition to financial risk protection: the extent of population coverage (eg who is covered) and the extent of health service coverage (eg what is covered) In some countries it will take many years to achieve universal coverage according to the above-mentioned dimensions This paper addresses a number of key questions that countries will need to address and considers how the responses can be tailored to the specific country context In addition, it highlights the critical need to pay attention to the role of institutional arrangements and organizations in implementing universal coverage Shifting to prepayment A first important observation is that many of the world's 13 billion people on very low incomes still do not have access to effective and affordable drugs, surgeries and other interventions because of weaknesses in the health financing system (1) We investigated 116 recent household expenditure surveys from 89 countries, which allowed calculations of the consequences of paying for health services by those who do use them Up to 13% of households face financial catastrophe in any given year because of the charges associated with using health services and up to 6% are pushed below the poverty line Extrapolating the results globally suggests that around 44 million households suffer severe financial hardship and 25 million are pushed into poverty each year simply because they need to use, and pay for, health services (7) Households are considered to suffer financial catastrophe if they spend more than 40% of their disposable income--the income remaining after meeting basic food expenditure--on health services They are often forced to reduce expenditure on other essential items such as housing, clothing and the education of children to pay for health services Households are considered impoverished if health expenses push them below the poverty line Inability to access health services, catastrophic expenditure and impoverishment are strongly associated with the extent to which countries rely on out-of-pocket payments as a means of financing their health systems These payments generally take the form of fees for services (levied by public and/ or private sector providers), co-payments where insurance does not cover the full cost of care, or direct expenditure for self-treatment often for pharmaceuticals A major challenge, therefore, to the achievement of universal coverage is finding ways to more away from out-of-pocket payments towards some form of prepayment Solutions are complex, and countries' economic, social and political contexts differ, moderating the nature and speed of development of prepayment mechanisms (8) Policy norms in health financing Health financing policy, however, cannot afford to focus just on how to raise revenues …

Universal Coverage of Health Services: Tailoring Its implementation/Couverture Universelle Des Services De Sante : Adaptation De Sa Mise En oeuvre/Cobertura Universal De Los Servicios De Salud: Adaptacion De Su Aplicacion

Access to care and medicines, burden of health care expenditures, and risk protection: results from the World Health Survey.

Employers and policy makers are increasingly turning to high-deductible health plans (HDHP) to control rising health care costs (Hilzenrath 2010) From 2006 to 2010 the percentage of employees covered by plans with at least a US$1000 deductible increased from 10 percent to 27 percent (Henry J Kaiser Family Foundation [KFF] 2010) Some analysts expect that the recently passed health insurance reform legislation will lead to an “explosion” in HDHP growth (Kerber 2010) However, the growing popularity of HDHPs has been accompanied by concern that members might underutilize necessary care due to prohibitive cost sharing (Parente, Feldman, and Christianson 2004; Dixon, Greene, and Hibbard 2008)

HDHPs require full cost sharing for most services until an annual deductible is met In 2010, average deductibles for commercial health plans (ie, HMO, PPO, POS, and savings option plans) with deductibles ranged from US$601 to US$1903 for individuals and US$1321 to US$3780 for families (KFF 2010) HDHPs associated with tax-advantaged Health Reimbursement Accounts (HRAs) or Health Savings Accounts (HSAs) to pay for qualifying medical expenses generally have higher deductibles than plans without spending accounts Many HDHPs aim to encourage high-value care such as primary care visits and preventive services by excluding them from the deductible (KFF 2010) Although tax laws require that HSA-associated HDHPs fully subject drugs to the deductible, the majority of HDHPs utilize tiered drug copayment structures similar to traditional health plans (KFF 2010)

Previous research provides compelling evidence that increased cost sharing reduces health care utilization (Newhouse 1993) The landmark RAND Health Insurance Experiment of 1971–1986 found that patients facing high-level cost sharing reduced overall utilization by approximately 33 percent (Newhouse et al 1981) and total spending by about 30 percent (Newhouse 1993) Both appropriate and inappropriate utilization decreased, including hospitalizations, outpatient visits, and preventive services (Lohr et al 1986; Newhouse 1993) The 2007/2008 National Health Interview Survey found that adults in HDHPs had 70 percent more unmet medical or prescription drug needs than adults in traditional health insurance plans (Cohen 2010) Studies have also demonstrated that HDHPs with full cost sharing for prescription drugs alter the use of essential medications for chronic illness, including antihypertensives, statins, cardiac medications, asthma controllers, hypoglycemics, epilepsy medications, and antiulcerants (Greene et al 2008; Nair et al 2009; Chen, Levin, and Gartner 2010)

However, no studies have examined whether HDHPs that selectively exclude medications from full cost sharing can mitigate or prevent this reduced utilization Such reductions could still occur if HDHP members (1) reduce contact with physicians due to cost sharing for services such as laboratory testing and radiology (providing fewer opportunities to receive prescriptions), (2) decide that overall increased levels of out-of-pocket payments for services under the deductible exceed their personal health care budget, causing reduced prescription drug purchasing, (3) are confused by complex benefit structures (Marquis 1981; Reed et al 2009), or (4) experience “sticker shock” and subsequent decreases in generalized utilization because of a very high cost health care event such as an emergency department visit or hospitalization (Wharam et al 2007)

We studied an HDHP that subjected prescription drugs to cost sharing levels typical of traditional health plans We examined its impact on drugs that reduce morbidity or mortality among patients with major chronic illnesses, including diabetes, hypertension, hyperlipidemia, and chronic pulmonary disease This research has major policy relevance because most HDHP members nationally face similar drug cost-sharing arrangements (KFF 2010)

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Effect of switching to a high-deductible health plan on use of chronic medications.

SA79 Association Between Antibiotic Exposure and Survival Among Patients Diagnosed With Advanced Melanoma or Advanced Non-Small Cell Lung Cancer (NSCLC) Treated With Immune Checkpoint Inhibitor (ICI) Therapy

SA27 Comparison of Comorbidity Indices Between Electronic Health Records (EHR) Derived Database and Claims Data Among Patients With Metastatic Breast Cancer

SA52 Assessing Missing Antineoplastic Therapy Prior to Electronic Health Record (EHR)-Derived First Line of Therapy after Advanced Non-Small Cell Lung Cancer (ANSCLC) Diagnosis

Sheila K. Reiss

Papers

Access to care and medicines, burden of health care expenditures, and risk protection: results from the World Health Survey.

Effect of switching to a high-deductible health plan on use of chronic medications.

SA79 Association Between Antibiotic Exposure and Survival Among Patients Diagnosed With Advanced Melanoma or Advanced Non-Small Cell Lung Cancer (NSCLC) Treated With Immune Checkpoint Inhibitor (ICI) Therapy

SA27 Comparison of Comorbidity Indices Between Electronic Health Records (EHR) Derived Database and Claims Data Among Patients With Metastatic Breast Cancer

SA52 Assessing Missing Antineoplastic Therapy Prior to Electronic Health Record (EHR)-Derived First Line of Therapy after Advanced Non-Small Cell Lung Cancer (ANSCLC) Diagnosis