Thursday, June 14, 2012

Patient Time Costs and Out-of-pocket Costs in Hepatitis C

From Liver International
Patient Time Costs and Out-of-pocket Costs in Hepatitis C
Carole A. Federico; Priscilla C. Hsu; Mel Krajden; Eric M. Yoshida; Karen E. Bremner; Alan A. Weiss; Frank H. Anderson; Murray D. Krahn

Discussion Only
View Full Text @ Medscape

We found that both time costs and OOP costs were substantial among HCV-infected patients. The average annual time loss attributable to HCV and its treatment varied from 69 h in early disease to 426 h among transplant recipients. For transplant recipients, this represented over 10 weeks of working time, or 20% of the average number of working hours among employed Canadians annually. We found that incomes among HCV patients were low, that many did not work, and those who had been successfully treated were much less likely to be unemployed. The burden borne by caregivers was also substantial: 3 weeks of time, on average, were spent by caregivers of transplant recipients.

Out-of-pocket health expenditures, even in a province with universal health insurance, were also substantial. Patients receiving active treatment and those with late-stage disease spent over $2000 per year on HCV-related healthcare, which represented approximately 7% of their annual income. Hospitalizations and visits to liver specialists resulted in large time losses. Visits to complementary and alternative healthcare practitioners were associated with very high OOP expenditures.

Perhaps our most striking result is the association between high cost and low income. Low-income earners spent significantly more time visiting health professionals and had significantly higher non-prescription medication costs than those reporting higher income. Furthermore, low-income earners (most of whom were unemployed) had significantly higher scores for comorbidity, suggesting that they had health burdens in addition to those from HCV. This suggests that the financial burden of HCV disproportionately affects those least able to afford it.

Disparities in HCV morbidity, mortality and access to treatment have been related to comorbidity, illicit drug use, and socioeconomic factors, such as race in other countries.[30–32] For example, African Americans and injection drug users represent a high proportion of HCV patients in the USA but experience many social, psychological and environmental barriers to HCV treatment. This lack of equity is recognized and is being addressed. Our study identified a different type of inequity within a publicly funded universal healthcare system. Patients who need more treatment are able to access such treatment but pay more for it in time and OOP costs than their healthier and wealthier counterparts.

Why are costs highest among the poor? One potential explanation is that those with low incomes and low employment rates have more uncommitted time, and therefore are freer to seek medical care. Alternatively, patients with low income levels live in geographically distant areas resulting in greater resources and time being spent commuting to seek healthcare services. Another, and perhaps more plausible explanation, is that low income is associated with a higher illness burden, and therefore a greater need for medical care; both individuals in the lowest income bracket and the unemployed have significantly more comorbid illnesses as measured by both Charlson and ICED comorbidity scores. We believe that the most likely explanation for the high costs associated with low income is the high illness burden in those with low socioeconomic status. Those who are most ill are less able to work and need more care.

The costs of HCV-related illness appear comparable to those for other diseases. Bernard et al.[33] examined the financial burden of diabetes among adults and compared them to burdens among adults with the 15 most costly medical conditions. They found that non-elderly adults spent approximately $1329 (USA) per year on OOP expenses related to their healthcare, a figure similar to our own annual OOP costs ($C 1326). Furthermore, Bernard et al. demonstrated that persons with diabetes are significantly more likely to have high burdens compared to those with heart disease, hypertension and cancer, suggesting that the burden of HCV may be greater than other chronic diseases. The OOP costs associated with depression are also in keeping with the costs of HCV, although the distribution of cost is quite different. Harman et al.[34] calculated annual OOP expenditures in older Americans to be $1835 (USA); 59% of OOP spending was for prescription drugs, 9% was for outpatient and office-based visits, and 3% was for inpatient and ER visits.

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