Strategies for reducing out of pocket payments in the

Jalali et al. Cost Eff Resour Alloc (2021) 19:47 https://doi.org/10.1186/s12962-021-00301-8

REVIEW

Strategies for reducing out of pocket payments in the health system: a scoping reviewFaride Sadat Jalali1, Parisa Bikineh1 and Sajad Delavari2*

Abstract

Background: Direct out-of-pocket payments (OOP) are among the most important financing mechanisms in many health systems, especially in developing countries, adversely affecting equality and leading vulnerable groups to pov-erty. Therefore, this scoping review study was conducted to identify the strategies involving OOP reduction in health systems.

Methods: Articles published in English on strategies related to out-of-pocket payments were Searched and retrieved in the Web of Science, Scopus, PubMed, and Embase databases between January 2000 and November 2020, follow-ing PRISMA guidelines. As a result, 3710 papers were retrieved initially, and 40 were selected for full-text assessment.

Results: Out of 40 papers included, 22 (55%) and 18 (45%) of the study were conducted in developing and devel-oped countries, respectively. The strategies were divided into four categories based on health system functions: health system stewardship, creating resources, health financing mechanisms, and delivering health services.As well, developing and developed countries applied different types of strategies to reduce OOP.

Conclusion: The present review identified some strategies that affect the OOP payments According to the health system functions framework. Considering the importance of stewardship, creating resources, the health financing mechanisms, and delivering health services in reducing OOP, this study could help policymakers make better deci-sions for reducing OOP expenditures.

Keywords: OOP, Out of pocket, Health policy, Health system, Financing, Scoping review

© The Author(s) 2021. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

IntroductionNowadays, spending on health is rising, accounting for 10% of global gross domestic product (GDP). Govern-ment expenditures, out-of-pocket payments (OOPs), and sources like voluntary health insurance, employer-pro-vided health programs, and activities by non-governmen-tal organizations are all included in health spending [1].

As defined by the World Health Organization (WHO), OOP expenses are the individuals’ direct payments to healthcare providers at the time of service use [2]. OOPs, include purely private transactions (payments made by individuals to private doctors and pharmacies), offi-cial patient cost-sharing (user fees/copayments) within defined public or private benefit packages, and informal payments (payments beyond the prescriptions entitled as benefits, both in cash and in-kind). Therefore, OOPs may be explicitly some part of a policy or can occur through market transactions, or both [3].

OOP health expenditures may increase whenever households opt to access and receive health services but are not protected against high payments since medical

Open Access

Cost Effectiveness and Resource Allocation

*Correspondence: [email protected] Health Human Resources Research Center, School of Health Management and Information Sciences, Shiraz University of Medical Sciences, Shiraz, IranFull list of author information is available at the end of the article

http://orcid.org/0000-0002-5539-9026

http://creativecommons.org/licenses/by/4.0/

http://creativecommons.org/publicdomain/zero/1.0/

http://creativecommons.org/publicdomain/zero/1.0/

http://crossmark.crossref.org/dialog/?doi=10.1186/s12962-021-00301-8&domain=pdf

Page 2 of 22Jalali et al. Cost Eff Resour Alloc (2021) 19:47

costs are high. They do not have access to insurance coverage and other safeguards against OOPs [4]. The following factors significantly affect OOP health care costs: increased patient cost-sharing, development of high-deductible health care plans, and more use of costly biologic or designer drugs. OOP payments are not an efficient way of financing health care and may negatively affect equity and cause vulnerable groups to experience poverty [5]. High OOP medical costs can use up financial savings and damage credits and have a negative impact on the quality of life, medication adherence, and different health outcomes [6].

A new report by the World Bank Group stated that OOP payments accounted for a non-negligible part of total health care expenditures in Central and Eastern European countries. Also, Patients in developing coun-tries spent half a trillion dollars each year (over $80 per person) out of their own pockets to receive health ser-vices [7]. Unfortunately, such expenses significantly harmed the poor [8]. The more the health sector grew, the less reliant it would be on OOP spending. The total OOP spending increased at least twice as much in low- and middle-income countries during 2000–2017 and reached 46% in high-income ones. However, its growth was slower than that of public spending in all income groups [9]. According to Adam Wagstaf (2020), OOP expenditures changed significantly within income groups, ranging from $32 in Sweden to $1200 in Switzer-land in the high-income groups, and from six dollars in Madagascar to $100 in Cambodia, Haiti, and Nepal in the low-income ones [10].

There have been health financing policy reforms and measures in several countries recently to deal with the concerns over high OOP payments. While there is no remedy, available information suggests that having well-designed policies and strategies can help countries reduce OOP and its adverse effects successfully [2, 11]. In general, reforms can apply some key strategies to abol-ish user fees or charges in public health facilities and exempt specific community groups such as the poor and

the vulnerable, and pregnant women and children from official payments. They should also exempt some health services such as maternal and child care from official payments and deliver them free of charge [12].

Due to the lack of resources, implementing effective policies can protect households against the common and high costs of the health system. To date, no known study has reviewed the proposed appreciate strategies for reducing OOP health payments worldwide. So, the pre-sent study aims to investigate strategies of reducing OOP payments in the health system through scoping review studies between 2000 and 2020. This review can help decision-makers learn from the effective experiences of other countries in reducing OOP health payments.

Materials and methodsThis study was carried out based on the Joanna Briggs Institute scoping review method as a framework [13], and a comprehensive systematic scoping review was per-formed to explain the strategies that could effectively reduce OOP health expenditures around the world. A defined question based on the PCC (Population, Con-cept, and Context) elements was raised at the first stage. All the countries in the world (Population), strategies and policies that affected OOP health expenditures (Concept), and all health systems having OOP payments (Context) were included in the question.

The second stage dealt with the target population, which comprised all the studies related to “Out-of-Pocket Expenditures” in various countries. To this end, all related studies conducted since 2000 were retrieved through the research strategy (Table 1).

Thus, the original English keywords appropriate to the research objective were first selected based on the com-ments of the research team and the keywords used in available related studies. Then, PubMed, Scopus, ISI Web of Science, and Embase databases were searched. It was decided to identify all the articles with at least an English abstract indexed in one database.

Table 1 The search strategy of the research

Search strategy

Databases: PubMed, Scopus, ISI Web of Science, Embase (2000–2020)

Limits: Language (resources in English) and date (published after 2000)

Date: up to November 25, 2020

Strategy: #1 AND #2 in title and abstract

#1 “Out-of-Pocket Expenditure” OR “Out-of-Pocket Payment” OR “Out-of-Pocket Cost” OR “Out-of-Pocket Spending” OR “Out-of-pocket health spending” OR “Out of Pocket Expenditures” OR “Out-of-Pocket Expenses” OR “OOP” OR “Out of pocket”

#2 Strategy OR intervention OR policy


The selection of the relevant studies was carried out in the third stage. First, 3710 articles were indexed in all databases. After deleting duplicates, 1474 English-language articles were selected for review. Then, 223 articles were excluded from the list after reviewing the titles and abstracts, and 108 were chosen to review the full-text, and finally, the research team chooses 40 papers (Fig. 1). It is worth mentioning that all of the research processes and selection of the papers were conducted by two researchers independently (FSJ and PB), and a third researcher was responsible for reach-ing consensus if necessary (SD). Also, the protocols

and review studies were not included in the present research. Finally, the Critical Appraisal Skills Pro-gram (CASP) tool was used to evaluate the quality of the original articles since it worked as a guide to cover the essential areas for critical appraisal of articles effectively.

In the last stage, the data were extracted from each study using the data-charting form (Appendix Table 4) and were collated and classified according to the the-matic analysis provided.

In stage four, the data-charting form was used to extract data from each study (Appendix Table 4). Then,

Records identified through databases (n=3710)

(Scopus:848, PubMed: 769, Embase: 1063, Web of Sciences: 1030)

Records after duplicates removed

(n=2236)

Article titles assessed for eligibility

(n=1474)

Article abstracts assessed for eligibility

(n=331)

Full-text articles assessed for eligibility

(n=108)

Records excluded

(n=1143)

Article abstracts excluded

(n=223)

Full text articles excluded,with reason

(n=68)

Studies included

(n=40)

Res

ourc

e id

entif

icat

ion

Scre

enin

gE

ligib

ility

Incl

uded

Fig. 1 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for thescoping review process


the collected data were collated and classified according to the thematic analysis in the last stage.

ResultsThe findings resulted from the analysis of 40 studies were summarized in Appendix Table 5. Among these studies, 20 (50%), 13 (32.5%), four (10%), and three (7.5%) stud-ies belonged to Asian, American, European, and African countries, respectively. Furthermore, 22 (55%) and 18 (45%) belonged to developing and developed countries.

Other findings show that four main factors have been emphasized as the effective factors on reducing OOP payments in the health systems, including Health system

stewardship, creating resources, the health financing mechanisms, and delivering health services (Table 2).

As it derives from Table 2, 31 (77.5%) articles pointed to the “role of the healthcare system stewardship” as one of the main components in reducing OOP payments. The three subcomponents under the tutelage include legis-lation (40.5%), legislation implementation (42.5%), and effective monitoring (17%).

The second most referred main component belonged to the "health financing mechanisms " with 18 articles (45%) and three subcomponents, namely revenue col-lection (19%), pooling and Resource management (57%), payment and purchasing (24%).

Table 2 Component affecting on out of pocket reducing

Main components Subcomponents References Reference evidence

Stewardship Regulatory [5, 14–31] -Developing clinical guidelines [17]-Pro-poor health financing policy focusing on financial protection

not only for those close to the poverty line, but also those who are already below it in both rural and urban areas [5]

-Inclusion of private providers in the system [29]

Implement regulations [15, 16, 18–20, 22, 23, 30–42] -Broadly implement DRGs and refine payment systems [33]-Universal health insurance coverage programs [28]-Create patient transport system in remote locations [38]

Regulatory monitoring [15, 18, 27, 29, 36–38, 43] -A need for federal and state policymakers to reexamine how state agencies are applying the cost-sharing protections for contraception under Medicaid and Medicaid managed care plans [27]

-Ensuring more investment for health from social health insur-ance and/or tax-based government funding [36]

Creating resources Facilities [5, 15, 32, 39, 44] -The need for availability of drugs and medical supplies at the public facility [15]

-Improving access to healthcare facilities like diagnostic test [32]-Telehealth (on-line video consultation) [44]

Personnel [17, 20, 27, 45, 46] -Training the physicians [17]-Physicians should develop the habit of using brief just-in-time

interventions at the point of prescription ordering [45]

Financing Revenue collection [5, 19, 29, 42] -Innovative financing mechanisms on the collection side to reduce the intensity of poverty [5]

-Exemption process of fees for the poor, disabled, and disadvan-taged [19]

Pooling [5, 20, 21, 24, 30, 31, 37, 42, 43, 46–48] -Mobilizing OOP payments on a pre-paid basis through formal or community-based risk-pooling schemes [24]

-Enrolment into health insurance [37]-Basic Insurance Scheme (BIS) (Retired workers are exempt from

premium contributions, and the cost of their contributions is to be borne by their former employers) [48]

Purchasing [5, 14, 18, 33, 49] -Diagnosis-related group (DRG)–based payment system [49]-Performance-based payment [14]

Delivering services Prevention [5, 16, 24, 27, 28, 31, 50, 51] -Screening and in situ treatment of precancerous cervical lesions for women between 25 and 55 years old [16]

-The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke [31]

-Breast cancer screening [51]-Integrating the prevention and control of oral diseases into

universal health insurance coverage programs [28]

Treatment [6, 15, 20, 27, 32, 39, 45, 50] -The improved effectiveness of services [15]-Limiting X-ray and ultrasound orders [50]-Switching to a generic form of intervention [6]


The number of article on “delivering health services” were 15 (37.5%). It has two sub-components of preven-tive services (50%), and treatment (50%) have been con-sidered as one of the main components affecting the reduction of OOP payments in health systems.

“Creating Resource” with ten articles (25%) and two sub-components, namely the physical resources (50%), human capital investment, and training (50%), also have the least referred in the articles.

As Table 3 shows, developed and developing countries have implemented various strategies to reduce OOP. Developed Asian countries have applied medical sub-sidy, universal health coverage, Choosing the right phar-macy, requesting inexpensive generic drugs by patients, the inclusion of dental care coverage in health insurance packages, control strategies drug price, performance-based payment, eliminating OOP costs for methods of contraception, choose a brand-name drug with a generic equivalent, free screening, drug coupons, promoting the quality of primary care services, ordering by physicians and telehealth as effective strategies in reducing OOP payments. Government support of public health insur-ance program, subsidy program for diseases with high economic burden, prevent and control chronic diseases, training the physicians, developing clinical guidelines, universal health coverage, diagnosis-related group (DRG) based payment system, expanding the dental health reform, providing care closer to home, Insurance for chil-dren, students, the elderly, the disabled, and other unem-ployed populations in urban regions groups not covered by basic health insurance catastrophic disease insurance, increase the efficiency and quality of care, free treat-ment to the vulnerable segment of the population, clear the system from informal payment, -innovative financ-ing mechanisms on the collection, pooling and purchas-ing side, free gynecologic screening and discharging patients earlier are some strategies that Asian developing countries such as Iran, India, China, Bangladesh and the Philippines and African countries such as Ethiopia and Ghana have implemented to reduce their OOP payments.

DiscussionOverall, the results showed that four main components—health system stewardship, financing mechanisms, ser-vice delivery, and creating resources—have been effective in reducing OOP payments in health systems of different countries. This category is similar to the functions intro-duced by the WHO report in 2000 [52].

Legislation, legislation implementation, and effective monitoring are considered as proposed subcomponents of the stewardship. The results of many studies have shown that health care governance around the world can reduce household health expenditures by legislation. For

example, Rahman et al. (2020), in their research in Bang-ladesh, stated that health care governance, strengthen-ing the rules and regulations related to care subsidies by public health centers, counseling and planning clin-ics for parents, and Community-based health centers for low-income consumers and patients with high eco-nomic burden can play an important role in reducing OOP healthcare costs [31]. Sarnak et al. (2017) cited federal government negotiations and legislation on the announcement of centralized prices. They approved drug ceiling rates in the United States as one factor in reducing OOP payments [22].

Ensuring implementation and monitoring the correct-ness of the laws by health system governance can also help reduce OOP payments. Several studies have iden-tified the implementation of laws and programs related to global health care coverage as a way to protect house-holds from these expenditures [22, 23, 28, 35, 36].

Control on the efficiency and quality of care and pay-ment systems [18], Careful monitoring to clear the informal payments [29, 37] and ensuring the supply and availability of essential medicines [38] is also helpful in this regard.

According to the present study results, by investing in human capital investment and training and physical facil-ities, OOP payments can also be reduced. Providing the infrastructure for online video consultation in Australia [44], improving access to health facilities in India [32], physicians’ training on various fields in Iran [17] and the United States [45], had been reported as effective strate-gies in reducing OOP.

On the other hand, the lack of financial protection has been recognized as a health system disease. OOP pay-ments are one of the major financing mechanisms in many developing countries and put the poor’s greatest pressure. Adequate financing and its functions, includ-ing revenue collection, risk pooling and purchasing, are introduced as the most important mechanisms in reduc-ing the share of direct OOP payment [53]. For example, Aryeetey et al. (2016), in their study in Ghana, stated that enrolment into health insurance would reduce OOP pay-ments by 80% [37].

Several studies have also expanded the intensity and health insurance coverage for dental services [21]، rare and incurable diseases treatment [31], and mentioned the support for vulnerable groups as effective factors in this regard [42]. A study in India found that using new meth-ods of health financing to collect, pooling and purchasing would reduce the severity of poverty and OOP payments [5], including pay for performances [14] and diagnosis-related groups (DRGs) payments [18, 33, 49].

Also in this research, the provision of prevention and treatment services have been included as two


Table 3 Implemented interventions in developed and developing countries

Interventions in developed countries Asia -Medical subsidy for children-Universal health coverage; this is achieved

through public health insurance

America -Prescription content and Choosing right phar-macy

-Writing 90-day prescriptions and choosing the lowest-cost generic drugs by Prescribers

-Requesting inexpensive generic drugs by patients

-Control strategies drug price-Employ centralized price and comparative and

cost-effectiveness research for determining price ceilings

-Universal health coverage-Strategies Involving Care-Plan Changes: Chang-

ing to lower-cost alternative intervention, Switching to generic form of intervention, changing dosage/frequency of intervention

-Strategies not involving care-plan changes: Changing logistics of care, ––Facilitating co-pay assistance or coupons, Providing free samples, changing or adding insurance plans

-Innovation in drug pricing to include value, the introduction of performance-based payment

-Removal of consumer cost-sharing for contracep-tives

-Federal coverage in eliminating OOP costs among privately insured women for at least some methods of contraception

-Improve private health plans-Choose a brand-name drug with a generic

equivalent-Free breast cancer screening-Drug coupons for multiple sclerosis-Adults individual insurance-The Medicare insurance-Prioritize public financing of services for the poor-Promoting the quality of primary care services;-Mobilizing OOP payments on a pre-paid basis

through formal or community-based risk-pool-ing schemes

-Using brief just-in-time interventions at the point of prescription ordering by physicians

-Discontinuing nonessential medicines-Use of an over-the-counter medicine as a

substitute-Refer the patient to a public aid agency or social

worker

Oceania -Telehealth (on-line video consultation)

Europe -Inclusion of dental care coverage in health insur-ance packages

-Integrating the prevention and control of oral diseases into universal health insurance cover-age programs


sub-components of providing health services. Some stud-ies have shown that taking precautionary measures can prevent many OOP payments in the future. Meda et al. (2019) stated that the implementation of screening pro-grams for gynecological diseases in reproductive age would prevent cancer in later years and thus will lead to individual financial protection [16].

The results of a study by Kastor et al. Showed that launching national prevent and control cancer, diabetes, cardiovascular disease, and stroke programs in India sig-nificantly reduces OOP payment [31].

It is worth mentioning that the studies obtained from the present study showed that in addition to preventive services, the providers’ behaviors and actions are also effective in reducing OOP payments. physicians can

Table 3 (continued)

Interventions in developing countries Asia -Government support of public health insurance program

-Subsidy program for diseases with a high eco-nomic burden

-Prevent and control chronic diseases-Training the physicians-Developing clinical guidelines-Universal health coverage-Diagnosis-related group (DRG)–based payment

system-Expanding the dental health reform-Providing care closer to home-Improve the effectiveness of services-Regularly updating the essential list of drugs

according to need of patients-Mandatory social insurance program for urban

employees-Insurance for children, students, the elderly, the

disabled, and other unemployed populations in urban regions groups not covered by basic health insurance

-Catastrophic Disease Insurance-Increase the efficiency and quality of care-National Program for Prevention and Control of

Cancer, Diabetes, Cardiovascular Disease, and Stroke

-Free treatment to the vulnerable segment of the population for the treatment of cancer and heart diseases

-Create patient transport system in remote loca-tions

-Fees exemption for the poor, disabled, and disadvantaged

-Public and private insurance-More investment for health from social health

insurance and tax-based government funding-Inclusion of private providers in the system-Decrease and even eliminate the copayments for

those at low-income levels-Clear the system from informal payments-Innovative financing mechanisms on the collec-

tion, pooling, and purchasing side

Africa -Free maternal health care policy-Screening and in situ treatment of precancerous

cervical lesions for women between 25 and 55 years old and clinical screening for breast cancer at age 15

-Limiting prescription of brand-name drugs, x-ray and ultrasound orders, screening tests, advanced lab tests, ward/ICU admission, surgery

-Discharging patients earlier-Refuse expensive drug requested by patients or

families-Reducing informal fees


replace generic drugs with brand drugs in their prescrip-tions [20, 39, 45] Limiting diagnostic-therapeutic tests and surgeries and preventing unnecessary admissions in special intensive care wards and alternative interven-tions, discharge patients quickly [50] And improve the quality and effectiveness of services [15, 18], play an effective role in reducing OOP payments.

Also, as this study shows, employing cost-effective-ness research for determining price ceilings, dental care coverage in health insurance packages, control strate-gies drug price, and on-line video consultation are some strategies implemented in developed countries. But developing countries have implemented strategies, such as government support of public health insurance programs, subsidy programs for diseases with high economic burdens, training the physicians, eliminate informal payments, and discharging patients earlier. Strategies such as free screening programs, universal health coverage, pay for performance, promoting the quality of care services and replacing the brand drug with generic have been common in both developed and developing countries. The reason for these differences can be sought in factors such as the medical capacity of countries, per capita government funding, differ-ent patterns of disease, the governing system, and the health financing system. A study in Iran cited economic factors, policy factors, social support organizations, insurance, cost of health services, tariffs, health services organizations, providers and consumers’ behaviors, and epidemiological conditions as factors influencing OOP health payments [54].

It should be noted that this study by a research team has reviewed articles related to effective solutions to reduce OOP payments in the health systems of different countries. The search strategy consisted of four electronic databases, and two independent researchers evaluated each article.

This study faces several limitations including limitations related to databases and search strategies by researchers. As well the suggested strategies were not surveyed regard-ing to effectiveness or cost. Therefore, more studies are needed to check the cost and effectiveness of suggested strategies for reducing OOP.

ConclusionOne of the most important characteristics of successful countries in providing maximum health for their commu-nities is the rationality of the financing method and maxi-mizing the share of the public sector in the share of OOP payments in health services so that people feel comfortable when the disease occurs. In case of disability and poverty, do not give up health services.

The present review identified the importance of each health system’s functions that affect the reduction of OOP payments. Given that OOP payments are the worst form of financing in any health system, the strategies proposed and successfully implemented worldwide must be con-sidered by policymakers when making future decisions to target health systems. Approach their goals, which include promoting health, increasing accountability, and equitable financial participation.

Appendix 1See Tables 4 and 5.

Table 4 A draft chart of data extraction

General information

Title of the manuscript

Article No Language

Year of the publication First author

Place (Country) Corresponding

Type of article Journal name

Article characteristics

Aims of the study

Study approach study design

Methodology

Sampling method study environment

Data collection study population

Data analysis sample size

Results

Main results

Conclusion

Recommendations

Limitations


Tabl

e 5

Sele

cted

Stu

dies

on

out o

f poc

ket r

educ

ing

stra

tegi

es

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

1D

isea

se-s

peci

fic o

ut-o

f-poc

ket

heal

thca

re e

xpen

ditu

re in

urb

an

Bang

lade

sh: a

Bay

esia

n an

alys

is

Md.

Mah

fuzu

r Rah

man

2020

Bang

lade

shRe

sear

ch A

rtic

leU

rban

are

as o

f Raj

shah

i15

93 h

ouse

hold

s-R

educ

ing

out o

f poc

ket p

aym

ents

, af

ter i

mpl

emen

ting

gove

rnm

ent

supp

orte

d/pu

blic

not

priv

ate

heal

th in

sura

nce

prog

ram

in L

MIC

co

untr

ies,

part

icul

arly

Vie

tnam

, C

hina

, and

the

Phili

ppin

es-T

o av

oid

unpr

edic

tabl

e m

edic

al

expe

nses

, the

Gov

ernm

ent o

f Ba

ngla

desh

sho

uld

star

t hea

lth

insu

ranc

e pr

ogra

m in

its

heal

th-

finan

cing

uni

t-Im

plem

enta

tion

of a

sub

sidy

pro

-gr

am fo

r dis

ease

s w

ith h

igh

eco-

nom

ic b

urde

n lik

e re

nal d

isea

ses,

canc

er, a

nd h

eart

dis

ease

s-M

ore

atte

ntio

n to

pre

vent

and

co

ntro

l chr

onic

dis

ease

s

2O

ver M

edic

atio

n an

d W

aste

of

Reso

urce

s in

Phy

sici

ans’

Pres

crip

-tio

ns: a

Cro

ss S

ectio

nal S

tudy

in

Sout

hwes

tern

Iran

Moh

amm

adre

za H

eyda

ri20

20Ira

nRe

sear

ch A

rtic

le39

2 ph

ysic

ians

-Tra

inin

g th

e ph

ysic

ians

-Dev

elop

ing

clin

ical

gui

delin

es

3Th

e eff

ect o

f a c

omm

unity

-bas

ed

heal

th in

sura

nce

on th

e ou

t-of

-po

cket

pay

men

ts fo

r util

izin

g m

edic

ally

trai

ned

prov

ider

s in

Ba

ngla

desh

Jaha

ngir

A. M

. Kha

n20

20Ba

ngla

desh

Orig

inal

Art

icle

1292

(646

insu

red

and

646

unin

-su

red)

hou

seho

lds

-The

CBH

I sch

eme

(com

mun

ity-

base

d he

alth

insu

ranc

e), a

nd c

ould

pu

sh th

e co

untr

y to

war

ds u

nive

rsal

he

alth

cov

erag

e

4St

rate

gies

to R

educ

e O

ut-o

f-Poc

ket

Med

icat

ion

Cost

s fo

r Can

adia

ns

Livi

ng w

ith H

eart

Fai

lure

Will

iam

F. M

cInt

yre

2020

Cana

daO

rigin

al A

rtic

leO

utpa

tient

pha

rmac

ies

in H

amil-

ton,

Ont

ario

-Pre

scrip

tion

cont

ent,

disp

ensi

ng

prac

tice,

and

pha

rmac

y ch

oice

can

re

mar

kabl

y im

pact

out

-of-p

ocke

t co

sts

for H

F m

edic

atio

ns-P

resc

riber

s ca

n re

duce

cos

ts b

y w

ritin

g 90

-day

pre

scrip

tions

and

ch

oosi

ng th

e lo

wes

t-co

st g

ener

ic

drug

s in

eac

h th

erap

eutic

cla

ss-P

atie

nts

shou

ld re

ques

t ine

xpen

sive

ge

neric

dru

gs

5Ec

onom

ic Im

plic

atio

ns o

f Chi

nese

D

iagn

osis

-Rel

ated

Gro

up–B

ased

Pa

ymen

t Sys

tem

s fo

r Crit

ical

ly Il

l Pa

tient

s in

ICU

s

Zhao

lin M

eng,

MM

ed20

20C

hina

Orig

inal

Res

earc

h66

79 c

ritic

ally

ill p

atie

nts

who

re

ceiv

ed in

tens

ive

care

in th

e 22

pu

blic

hos

pita

ls)

-Chi

nese

dia

gnos

is-r

elat

ed g

roup

, (C

-DRG

)–ba

sed

paym

ent s

yste

m

achi

eved

suc

cess

in re

duci

ng O

OP

paym

ents

for c

ritic

ally

ill p

atie

nts

by s

hift

ing

the

paym

ent o

f OO

P co

sts

from

FFS

to D

RG


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

6Fa

ctor

s as

soci

ated

with

dis

parit

ies

in o

utof

-poc

ket e

xpen

ditu

re o

n de

ntal

car

e: re

sults

from

two

cros

s-se

ctio

nal n

atio

nal s

urve

ys

Ore

nste

in, L

2020

Occ

upie

d Pe

last

ine

Orig

inal

Res

earc

h A

rtic

le84

65 h

ouse

hold

s in

201

4 an

d 87

92

hous

ehol

ds-E

xpan

ding

the

dent

al h

ealth

refo

rm

and

addr

essi

ng b

arrie

rs to

pre

ven-

tive

dent

al c

are

-Exp

andi

ng b

asic

and

sup

plem

en-

tary

den

tal h

ealth

insu

ranc

e

7A

new

hop

e: fr

om n

egle

ct o

f the

he

alth

sec

tor t

o as

pira

tions

for

Uni

vers

al H

ealth

Cov

erag

e in

M

yanm

ar

Ale

x Er

go1

2019

Mya

nmar

Orig

inal

Pap

er36

48 h

ouse

hold

s in

Mya

nmar

-Con

fiden

ce o

f ser

vice

s de

liver

y ar

e av

aila

ble

at p

ublic

faci

litie

s-T

he a

vaila

bilit

y of

ser

vice

s cl

oser

by

-Impr

ove

effec

tiven

ess

of s

ervi

ces

-Nec

essa

ry d

rugs

and

med

ical

sup

-pl

ies

shou

ld b

e av

aila

ble

at th

e pu

blic

faci

lity

8O

ut-o

f-poc

ket p

aym

ents

in th

e co

ntex

t of a

free

mat

erna

l hea

lth

care

pol

icy

in B

urki

na F

aso:

a

natio

nal c

ross

-sec

tiona

l sur

vey

Ivla

bèhi

ré B

ertr

and

Med

a20

19Bu

rkin

a Fa

soO

rigin

al R

esea

rch

Wom

en (n

= 5

93) w

ho h

ad d

eliv

-er

ed o

r rec

eive

d ob

stet

ric c

are

on th

e da

y of

the

surv

ey

-Fre

e m

ater

nal h

ealth

car

e po

licy

-Ant

enat

al c

are,

nor

mal

del

iver

ies

and

EmO

NC

, cur

ativ

e ca

re d

urin

g pr

egna

ncy

and

up to

42

days

aft

er

deliv

ery,

trea

tmen

t of o

bste

tric

fis

tula

s, sc

reen

ing

and

in s

itu

trea

tmen

t of p

reca

ncer

ous

cerv

ical

le

sion

s fo

r wom

en b

etw

een

25 a

nd

55 y

ears

old

and

clin

ical

scr

eeni

ng

for b

reas

t can

cer s

tart

ing

at a

ge 1

5-Im

prov

emen

ts in

the

man

agem

ent

and

supp

ly s

yste

m o

f hea

lth fa

cili-

ties’

phar

mac

ies


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

9Fi

nanc

ial r

isk

prot

ectio

n at

the

bed-

side

: how

Eth

iopi

an p

hysi

cian

s tr

y to

min

imiz

e ou

t of p

ocke

t he

alth

exp

endi

ture

s

Ingr

id M

iljet

eig

2019

Ethi

opia

Rese

arch

Art

icle

565

phys

icia

ns-L

imiti

ng p

resc

riptio

n of

bra

nd

nam

ed d

rugs

/hos

pita

l dru

gs-E

xpla

inin

g al

tern

ativ

es a

nd re

com

-m

endi

ng a

fford

able

opt

ions

-Lim

iting

x-r

ay a

nd u

ltras

ound

ord

ers

-Pro

vidi

ng s

econ

d be

st tr

eatm

ent

-Lim

iting

scr

eeni

ng te

sts

-Lim

iting

adv

ance

d la

b te

sts

-Lim

iting

war

d/IC

U a

dmis

sion

-Dis

char

ging

pat

ient

s ea

rlier

than

yo

u w

ante

d-L

imiti

ng s

urge

ry u

nles

s hi

ghly

in

dica

ted

-Del

ayin

g a

trea

tmen

t or t

est t

o se

e if

poss

ible

to d

o w

ithou

t it

-Ref

errin

g pa

tient

s to

oth

er le

ss

expe

nsiv

e op

tions

-Pro

vidi

ng le

ss fr

eque

nt fo

llow

up

of

NC

Ds

(chr

onic

con

ditio

ns)

-Lim

iting

CT

or M

RI o

rder

s-N

ot in

form

ing

the

patie

nt a

bout

ex

pens

ive

optio

ns-S

cree

ning

pat

ient

for d

ialy

sis

-Ref

use

expe

nsiv

e dr

ug re

ques

ted

by

patie

nts

or fa

mili

es

10H

ealth

fina

ncin

g st

rate

gies

to

redu

ce o

ut-o

f-poc

ket b

urde

n in

Indi

a: a

com

para

tive

stud

y of

th

ree

stat

es

Mon

tu B

ose

2018

Indi

aCo

mpa

rativ

e St

udy

Rese

arch

Art

icle

3917

hou

seho

lds

from

TN

, 291

2 ho

useh

olds

in R

ajas

than

and

50

19 h

ouse

hold

s fro

m W

B

-Pro

curin

g m

edic

ine

or re

gula

rly

upda

ting

the

esse

ntia

l lis

t of d

rugs

ac

cord

ing

to n

eed

of p

atie

nts

are

urge

ntly

requ

ired

in W

est B

enga

l-Im

prov

ing

acce

ss to

hea

lthca

re

faci

litie

s lik

e di

agno

stic

test

etc

-TN

and

Raj

asth

an h

ealth

fina

ncin

g st

rate

gies


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

11Re

duci

ng th

e m

edic

al e

cono

mic

bu

rden

of h

ealth

insu

ranc

e in

C

hina

: Ach

ieve

men

ts a

nd c

hal-

leng

es

Dou

, G. S

2018

Chi

naPo

licy

Foru

m–

-Est

ablis

h a

man

dato

ry s

ocia

l ins

ur-

ance

pro

gram

for u

rban

em

ploy

-ee

s-E

stab

lish

the

New

Rur

al C

oope

rativ

e M

edic

al S

chem

e (N

CM

S)-E

stab

lish

Urb

an R

esid

ent B

asic

M

edic

al In

sura

nce

(URB

MI)

for

Chi

ldre

n, s

tude

nts,

the

elde

rly, t

he

disa

bled

, and

oth

er u

nem

ploy

ed

popu

latio

ns in

urb

an re

gion

s gr

oups

not

cov

ered

by

basi

c he

alth

in

sura

nce

-Incr

ease

gov

ernm

ent s

ubsi

dies

to

NC

MS

and

URB

MI t

o an

unp

rec-

eden

ted

scal

e-L

aunc

h Ca

tast

roph

ic D

isea

se In

sur-

ance

-Rep

lace

FFS

with

oth

er fo

rms

of

pros

pect

ive

paym

ent (

pros

pec-

tive

paym

ent s

yste

ms

such

as

the

glob

al b

udge

t pay

men

t sys

tem

-DRG

pay

men

ts-In

crea

se th

e effi

cien

cy a

nd q

ualit

y of

car

e un

der c

urre

nt p

aym

ent

syst

ems

12D

isea

se-s

peci

fic o

ut-o

f-poc

ket a

nd

cata

stro

phic

hea

lth e

xpen

ditu

re

on h

ospi

taliz

atio

n in

Indi

a: d

o In

dian

hou

seho

lds

face

dis

tres

s he

alth

fina

ncin

g?

Ans

hul K

asto

r20

18In

dia

Rese

arch

Art

icle

3,33

,104

indi

vidu

als

from

65,

932

hous

ehol

ds (3

6,48

0 ru

ral a

nd

29,4

52 u

rban

hou

seho

lds)

-The

Min

istr

y of

Hea

lth a

nd F

amily

W

elfa

re, G

over

nmen

t of I

ndia

la

unch

ed th

e N

atio

nal P

rogr

am fo

r Pr

even

tion

and

Cont

rol o

f Can

cer,

Dia

bete

s, Ca

rdio

vasc

ular

Dis

ease

an

d St

roke

-Sug

gest

for i

nclu

ding

trea

tmen

t of

canc

er, h

eart

dis

ease

s, an

d ot

her

rare

and

incu

rabl

e di

seas

es in

the

ambi

t of t

he h

ealth

insu

ranc

e co

vera

ge-P

rovi

de fr

ee tr

eatm

ent t

o th

e vu

l-ne

rabl

e se

gmen

t of t

he p

opul

atio

n fo

r the

trea

tmen

t of c

ance

r and

he

art d

isea

ses

-The

cov

erag

e an

d th

e in

sura

nce

amou

nt o

f the

RSB

Y ne

ed to

be

enla

rged


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

13D

oes

publ

ic h

ealth

sys

tem

pro

vide

ad

equa

te fi

nanc

ial r

isk

prot

ec-

tion

to it

s cl

ient

s? O

ut o

f poc

ket

expe

nditu

re o

n in

patie

nt c

are

at s

econ

dary

leve

l pub

lic h

ealth

in

stitu

tions

: cau

ses

and

dete

rmi-

nant

s in

an

east

ern

Indi

an s

tate

Rout

, S. K

2018

Indi

aRe

sear

ch A

rtic

le23

9 in

patie

nts

-Hea

lth s

yste

m s

houl

d en

sure

sup

ply

of e

ssen

tial m

edic

ines

and

cre

ate

patie

nt tr

ansp

ort s

yste

m in

rem

ote

loca

tions

to re

duce

OO

PE

14Th

e im

pact

of o

ut-o

f-poc

ket

paym

ents

for d

enta

l car

e on

ho

useh

old

finan

ces

in lo

w a

nd

mid

dle

inco

me

coun

trie

s

Edua

rdo

Bern

abé

2017

Lond

onRe

sear

ch A

rtic

le40

low

and

mid

dle

inco

me

coun

trie

s(1

,74,

257

adul

ts, a

ged

18 y

ears

and

ab

ove)

-Incl

usio

n of

den

tal c

are

cove

rage

in

heal

th in

sura

nce

pack

ages

-Inte

grat

ing

the

prev

entio

n an

d co

ntro

l of o

ral d

isea

ses

into

uni

-ve

rsal

hea

lth in

sura

nce

cove

rage

pr

ogra

ms

15Pr

edic

tors

of h

igh

out-

of-p

ocke

t he

alth

care

exp

endi

ture

: an

anal

y-si

s us

ing

Bang

lade

sh h

ouse

hold

in

com

e an

d ex

pend

iture

sur

vey,

20

10

Aza

her A

li M

olla

2017

Bang

lade

shRe

sear

ch A

rtic

le64

0 ru

ral a

nd 3

60 u

rban

hous

ehol

ds-P

rovi

ding

a s

afet

y ne

t for

low

-in

com

e ru

ral h

ouse

hold

s an

d fo

r el

derly

mem

bers

-Con

trol

and

pre

vent

ion

of c

hron

ic

dise

ases

-Uni

vers

al c

over

age

of h

ealth

care

-Lau

nchi

ng s

ome

new

type

s of

sa

fety

net

for t

he p

oor,

the

disa

-bl

ed a

nd w

omen

-Exe

mpt

ion

proc

ess

of fe

es fo

r the

po

or, d

isab

led

and

disa

dvan

tage

d

16Pa

ying

for P

resc

riptio

n D

rugs

A

roun

d th

e W

orld

: Why

Is th

e U

.S.

an O

utlie

r?

Dan

a O

. Sar

nak

2017

U.S

Issu

e Br

ief

Phar

mac

eutic

al s

pend

ing

in h

igh-

inco

me,

indu

stria

lized

cou

ntrie

s-C

ontr

ol s

trat

egie

s dr

ug p

rice

-Em

ploy

cen

tral

ized

pric

e, n

ego-

tiatio

ns, n

atio

nal f

orm

ular

ies,

and

com

para

tive

and

cost

-effe

ctiv

e-ne

ss re

sear

ch fo

r det

erm

inin

g pr

ice

ceili

ngs

-Fed

eral

gov

ernm

ent s

houl

d ne

goti-

ate

low

er d

rug

pric

es fo

r Med

icar

e be

nefic

iarie

s-U

nive

rsal

hea

lth c

over

age


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

17W

hat S

trat

egie

s D

o Ph

ysic

ians

an

d Pa

tient

s D

iscu

ss to

Red

uce

Out

-of-P

ocke

t Cos

ts?

Ana

lysi

s of

Co

st-S

avin

g St

rate

gies

in 1

755

Out

patie

nt C

linic

Vis

its

Wyn

n G

. Hun

ter

2016

Am

eric

aO

rigin

al A

rtic

lePa

tient

s w

ith b

reas

t can

cer,

depr

es-

sion

, rhe

umat

oid

arth

ritis

vis

iting

on

colo

gist

s, ps

ychi

atris

ts, a

nd

rheu

mat

olog

ist

Stra

tegi

es In

volv

ing

Care

-Pla

n C

hang

es C

hang

ing

to lo

wer

-cos

t alte

rnat

ive

inte

rven

tion

Sw

itchi

ng to

gen

eric

form

of i

nter

-ve

ntio

n C

hang

ing

dosa

ge/f

requ

ency

of

inte

rven

tion

Sto

ppin

g or

with

hold

ing

inte

rven

-tio

nSt

rate

gies

not

invo

lvin

g ca

re-p

lan

chan

ges

Cha

ngin

g lo

gist

ics

of c

are

Fac

ilita

ting

co-p

ay a

ssis

tanc

e or

co

upon

s P

rovi

ding

free

sam

ples

Cha

ngin

g or

add

ing

insu

ranc

e pl

ans

18Ca

n he

alth

insu

ranc

e pr

otec

t ag

ains

t out

of-p

ocke

t and

ca

tast

roph

ic e

xpen

ditu

res

and

also

sup

port

pov

erty

redu

ctio

n?

Evid

ence

from

Gha

na’s

Nat

iona

l H

ealth

Insu

ranc

e Sc

hem

e

Gen

evie

ve C

ecili

a A

ryee

tey

2016

Gha

naO

rigin

al30

00 h

ouse

hold

s-E

nrol

men

t int

o he

alth

insu

ranc

e re

duce

d ho

useh

old

cost

s-P

rote

ctiv

e eff

ect o

f the

NH

IS-R

educ

e in

form

al fe

es

19Th

e fin

anci

al b

urde

n of

out

-of-

pock

et e

xpen

ses

in th

e U

nite

d St

ates

and

Can

ada:

How

diff

eren

t is

the

Uni

ted

Stat

es?

Kath

erin

e E

Baird

2016

Cana

daO

rigin

al A

rtic

le2,

03,7

99U

nite

d St

ates

60,3

13Ca

nada

Hou

seho

lds

-Exp

ansi

on in

insu

ranc

e le

vels

-The

AC

A’s

to m

atch

the

actu

aria

l va

lue

of in

sura

nce

to in

com

e, a

nd

to p

lace

mor

e st

ringe

nt li

mits

20Th

e Pa

rity

Para

digm

: Can

Leg

isla

-tio

n H

elp

Redu

ce th

e Co

st

Burd

en o

f Ora

l Ant

ican

cer

Med

icat

ions

?

Shee

tal M

. Kirc

her

2016

Chi

cago

Polic

y Pe

rspe

ctiv

e–

-Inno

vatio

n in

dru

g pr

icin

g to

in

clud

e va

lue,

intr

oduc

tion

of

perf

orm

ance

-bas

ed p

aym

ent,

and

a sh

ift fr

om c

over

age

base

d on

the

rout

e of

adm

inis

trat

ion

21W

omen

Saw

Lar

ge D

ecre

ase

In

Out

-Of-P

ocke

t Spe

ndin

g Fo

r Co

ntra

cept

ives

Aft

er A

CA

Man

-da

te R

emov

ed C

ost S

harin

g

Beck

er, N

. V20

15U

nite

d St

ates

Orig

inal

Wom

en a

ges

13–4

5 w

ho w

ere

enro

lled

in p

rivat

e he

alth

insu

r-an

ce

AC

A-m

anda

ted

rem

oval

of c

on-

sum

er c

ost s

harin

g fo

r pre

scrip

tion

cont

race

ptiv

es (p

ill a

nd IU

D) i

n no

n gr

andf

athe

red

insu

ranc

e pl

ans

22Pa

ymen

t ref

orm

pilo

t in

Beiji

ng

hosp

itals

redu

ced

expe

nditu

res

and

out-

of-p

ocke

t pay

men

ts p

er

adm

issi

on

Jian,

W20

15Be

ijing

Orig

inal

Shift

ing

paym

ent o

f 108

dia

gnos

es

or p

roce

dure

s fro

m F

FS p

aym

ent

to a

DRG

at s

ix te

rtia

ry g

ener

al

hosp

itals

-Bro

adly

impl

emen

t DRG

s an

d re

fine

paym

ent s

yste

ms


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

23C

hang

es in

out

-of-p

ocke

t pay

-m

ents

for c

ontr

acep

tion

by

priv

atel

y in

sure

d w

omen

dur

ing

impl

emen

tatio

n of

the

fede

ral

cont

race

ptiv

e co

vera

ge re

quire

-m

en

Law

renc

e B.

Fin

er20

14A

mer

ica

Orig

inal

rese

arch

art

icle

3207

wom

en a

ged

18–3

9 ye

ars

-Fed

eral

cov

erag

e in

elim

inat

ing

out-

of-p

ocke

t cos

ts a

mon

g pr

ivat

ely

insu

red

wom

en fo

r at l

east

som

e m

etho

ds o

f con

trac

eptio

n-Im

prov

e pr

ivat

e he

alth

pla

ns-C

hoos

e a

bran

d-na

me

drug

with

a

gene

ric e

quiv

alen

t-A

nee

d fo

r fed

eral

and

sta

te p

olic

y-m

aker

s to

reex

amin

e ho

w th

e co

st

shar

ing

prot

ectio

ns fo

r con

trac

ep-

tion

unde

r Med

icai

d ar

e be

ing

appl

ied

by s

tate

age

ncie

s an

d M

edic

aid

man

aged

car

e pl

ans

-Sub

sidi

zed

care

pro

vide

d by

pu

blic

ly s

uppo

rted

hea

lth c

ent-

ers,

such

as

heal

th d

epar

tmen

ts,

Plan

ned

Pare

ntho

od c

linic

s an

d co

mm

unity

hea

lth c

ente

rs, t

o lo

w-

inco

me

clie

nts

24U

nder

stan

ding

Pat

ient

Opt

ions

, U

tiliz

atio

n Pa

tter

ns, a

nd B

urde

ns

Ass

ocia

ted

with

Bre

ast C

ance

r Sc

reen

ing

Har

vey,

S. C

2014

Am

eric

a–

–-B

reas

t can

cer s

cree

ning

(pat

ient

re

call

for f

urth

er d

iagn

ostic

imag

-in

g or

pro

cedu

res)

-Fre

e br

east

can

cer s

cree

ning

25Sp

ecia

lty D

rug

Coup

ons

Low

er

Out

-Of-P

ocke

t Cos

ts A

nd M

ay

Impr

ove

Adh

eren

ce A

t The

Ris

k O

f Inc

reas

ing

Prem

ium

s

Star

ner,

C. I

2014

Uni

ted

Stat

esO

rigin

al2,

64,8

01ph

arm

acy’

s pr

escr

iptio

ns-D

rug

coup

ons

for m

ultip

le s

cler

osis

or

bio

logi

c an

ti-in

flam

mat

ory

drug

s


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

26H

ealth

-Rel

ated

Fin

anci

al C

atas

-tr

ophe

, Ine

qual

ity a

nd C

hron

ic

Illne

ss in

Ban

glad

esh

Md.

Miz

anur

Rah

man

120

13Ba

ngla

desh

Orig

inal

Art

icle

Urb

an a

reas

of R

ajsh

ahi

1593

hou

seho

lds

-Impl

emen

ting

com

puls

ory

heal

th

insu

ranc

e fo

r sal

arie

d w

orke

rs in

bo

th p

ublic

and

priv

ate

sect

ors,

and

volu

ntar

y m

embe

rshi

ps fo

r de

pend

ents

, far

mer

s an

d se

lf-em

ploy

ed p

erso

ns-Im

prov

ing

rout

ine

man

agem

ent

of N

CD

s, to

redu

ce th

e co

st o

f ch

roni

c di

seas

e m

anag

emen

t, an

d in

corp

orat

ing

chro

nic

dise

ase

man

agem

ent i

nto

publ

ic s

ervi

ces

and

heal

th fi

nanc

ing

initi

ativ

es,

to e

nsur

e th

at th

is e

xpen

ditu

re

is in

clud

ed in

risk

poo

ling

and

wel

fare

initi

ativ

es a

nd th

e hi

gh

OO

P pa

ymen

ts a

ssoc

iate

d w

ith

chro

nic

illne

ss-In

corp

orat

ing

anci

llary

ser

vice

s in

to b

asic

car

e pa

ckag

es in

pub

lic

faci

litie

s

27Th

e im

pact

of h

ealth

insu

ranc

e pr

ogra

ms

on o

ut-o

f-poc

ket

expe

nditu

res

in In

done

sia:

an

incr

ease

or a

dec

reas

e?

Budi

Aji

2013

Indo

nesi

aO

rigin

al A

rtic

leIn

done

sia

Fam

ily L

ife S

urve

y (IF

LS)

data

set

cove

ring

7224

hou

seho

lds

This

stu

dy s

how

ed th

at tw

o la

rge

exis

ting

heal

th in

sura

nce

prog

ram

s in

Indo

nesi

a, A

skes

kin

and

Ask

es.

The

abili

ty o

f pro

gram

s to

offe

r fin

anci

al p

rote

ctio

n by

redu

cing

ou

t-of

-poc

ket e

xpen

ditu

res

is li

kely

to

be

a di

rect

func

tion

of th

eir

bene

fits

pack

age

and

co-p

aym

ent

polic

ies


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

28Th

e he

alth

car

e sy

stem

refo

rm in

C

hina

: eec

ts o

n ou

t-of

-poc

ket

expe

nses

and

sav

ing

Ate

lla, V

2013

Chi

naO

rigin

al A

rtic

leIn

divi

dual

s an

d ho

useh

olds

from

11

pro

vinc

es a

nd m

unic

ipal

ities

fro

m H

ouse

hold

Inco

me

Proj

ect

surv

eys

-The

third

sta

ge o

f the

hea

lth c

are

syst

em re

form

, Bas

ic In

sura

nce

Sche

me

(BIS

). (T

he p

rogr

am is

fin

ance

d by

pre

miu

m c

ontr

ibu-

tions

from

em

ploy

ers

and

empl

oy-

ees.

Retir

ed w

orke

rs a

re e

xem

pt

from

pre

miu

m c

ontr

ibut

ions

and

th

e co

st o

f the

ir co

ntrib

utio

ns is

to

be b

orne

by

thei

r for

mer

em

ploy

-er

s. hi

s pr

ogra

m e

xpan

ds c

over

age

to p

rivat

e en

terp

rises

and

sm

alle

r pu

blic

ent

erpr

ises

. Mor

eove

r, se

lf-em

ploy

ed w

orke

rs a

re a

llow

ed to

en

ter t

he p

rogr

am.)

-Pub

lic a

nd p

rivat

e in

sura

nce

prov

e to

ser

ve a

s a

cush

ion

agai

nst

heal

th ri

sks

29Pr

actic

al a

spec

ts o

f tel

ehea

lth:

finan

cial

con

side

ratio

nsLo

h, P

. K20

13A

ustr

alia

Orig

inal

–-T

eleh

ealth

(onl

ine

vide

o co

nsul

ta-

tion)

sav

e tr

avel

tim

e fo

r pat

ient

s, ca

reer

s an

d sp

ecia

lists

, and

can

re

duce

out

-of-p

ocke

t exp

ense

s

30O

ut-o

f-poc

ket m

edic

al e

xpen

ses

for i

npat

ient

car

e am

ong

bene

ficia

ries

of th

e N

atio

nal

Hea

lth In

sura

nce

Prog

ram

in th

e Ph

ilipp

ines

Tobe

, M20

13Ph

ilipp

ines

Orig

inal

94,5

31 in

sura

nce

clai

ms

-Ens

urin

g m

ore

inve

stm

ent f

or

heal

th fr

om s

ocia

l hea

lth in

sura

nce

and/

or ta

x-ba

sed

gove

rnm

ent

fund

ing,

as

wel

l as

shift

ing

the

pro-

vide

r pay

men

t mec

hani

sm fr

om

a fe

e-fo

r-se

rvic

e to

a c

ase-

base

d pa

ymen

t met

hod,

is e

ssen

tial

-NH

IP (N

atio

nal H

ealth

Insu

ranc

e Pr

ogra

m in

the

Phili

ppin

es)

31Co

mm

unity

pha

rmac

y-ba

sed

med

icat

ion

ther

apy

man

age-

men

t ser

vice

s: fin

anci

al im

pact

fo

r pat

ient

s

Dod

son,

S. E

2012

Am

eric

aO

rigin

al R

esea

rch

Med

icar

e Pa

rt D

mem

bers

who

ha

d be

en p

revi

ousl

y id

entifi

ed a

s el

igib

le fo

r MTM

ser

vice

s(1

28 p

atie

nts)

-Pat

ient

par

ticip

atio

n in

MTM

se

rvic

es(M

edic

atio

n Th

erap

y M

anag

emen

t)

32Im

pact

of h

ealth

care

refo

rms

on

out-

of-p

ocke

t hea

lth e

xpen

di-

ture

s in

Tur

key

for p

ublic

insu

rees

Erus

, B20

12Tu

rkey

Orig

inal

Pap

erH

ouse

hold

Bud

get S

urve

y-In

clus

ion

of p

rivat

e pr

ovid

ers

in th

e sy

stem

-Dec

reas

e an

d ev

en e

limin

ate

the

co-p

aym

ents

for t

hose

at l

ow-

inco

me

leve

ls-C

lear

the

syst

em fr

om in

form

al

paym

ents


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

33In

divi

dual

Insu

ranc

e Be

nefit

s To

Be

Ava

ilabl

e U

nder

Hea

lth R

efor

m

Wou

ld H

ave

Cut O

ut-O

f-Poc

ket

Spen

ding

In 2

001–

08

Hill

, S. C

2012

Rock

ville

, Mar

ylan

dO

rigin

alA

dults

age

s 26

–64

with

indi

vidu

al

insu

ranc

e, in

sura

nce

thro

ugh

smal

l em

ploy

ers,

insu

ranc

e th

roug

h la

rge

empl

oyer

s

-Adu

lts in

divi

dual

insu

ranc

e re

duce

ris

k fo

r hig

h ou

t-of

-poc

ket s

pend

-in

g an

d lo

wer

ave

rage

out

of-

pock

et c

osts

for m

edic

al c

are

and

pres

crip

tion

drug

s

34In

sure

d ye

t vul

nera

ble:

out

-of-

pock

et p

aym

ents

and

Indi

a’s

poor

Shah

raw

at, R

2012

Indi

aO

rigin

al1,

24,6

44 (4

5 34

6 ur

ban

and

79,2

98

rura

l) ho

useh

olds

-No

OO

P pa

ymen

ts fo

r dru

gs, f

or

inpa

tient

and

for o

utpa

tient

vi

sits

—on

impo

veris

hmen

t-N

eed

to e

xpan

d pr

ogra

m b

enefi

ts

beyo

nd in

patie

nt c

are

-Insu

ranc

e sc

hem

es li

ke th

e RS

BY

whi

ch fo

cus

on th

e po

or a

re a

n im

port

ant n

ew in

itiat

ive

to re

duce

th

e im

pove

rishi

ng e

ffect

s of

OO

P pa

ymen

t for

hea

lth-In

sura

nce

sche

mes

targ

etin

g th

e po

or n

eed

to h

ave

a su

ffici

ently

w

ide

cove

rage

35Pr

omot

ing

Acc

ess

and

Redu

cing

Ex

pect

ed O

ut-o

f-Poc

ket P

resc

rip-

tion

Dru

g Co

sts

for V

ulne

rabl

e M

edic

are

Bene

ficia

ries

Tim

othy

W. C

utle

r20

11Ca

lifor

nia

Brie

f Rep

ort

Vuln

erab

le M

edic

are

bene

ficia

ries

-Vul

nera

ble

Med

icar

e be

nefic

iarie

s sh

ould

rece

ive

assi

stan

ce fr

om

phar

mac

ists

and

trai

ned

phar

mac

y st

uden

ts a

nd e

nrol

l in

the

low

est-

cost

pla

ns-T

he M

edic

are

Part

D b

enefi

ts

36Eff

ect o

f a m

edic

al s

ubsi

dy o

n he

alth

ser

vice

util

izat

ion

amon

g sc

hool

child

ren:

A c

omm

unity

-ba

sed

natu

ral e

xper

imen

t in

Japa

n

Miy

awak

i, A

2010

Japa

nO

rigin

alC

hild

ren

who

wer

e in

gra

des

1–6

-Med

ical

sub

sidy

for c

hild

ren

(MSC

)-U

nive

rsal

hea

lth c

over

age;

this

is

achi

eved

thro

ugh

publ

ic h

ealth

in

sura

nce


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

37Re

duci

ng o

ut-o

f-poc

ket e

xpen

di-

ture

s to

redu

ce p

over

ty: a

dis

ag-

greg

ated

ana

lysi

s at

rura

l–ur

ban

and

stat

e le

vel i

n In

dia

Gar

g, C

. C20

09In

dia

Com

para

tive

Stud

y1,

20,0

00 h

ouse

hold

-Rat

iona

lized

dru

g po

licie

s (in

clud

ing

free

supp

lies)

-Pro

-poo

r hea

lth fi

nanc

ing

polic

y fo

cusi

ng o

n fin

anci

al p

rote

ctio

n no

t onl

y fo

r tho

se c

lose

to th

e po

v-er

ty li

ne, b

ut a

lso

thos

e w

ho a

re

alre

ady

belo

w it

in b

oth

rura

l and

ur

ban

area

s; an

d in

nova

tive

finan

c-in

g m

echa

nism

s on

the

colle

ctio

n,

pool

ing

and

purc

hasi

ng s

ide

to

redu

ce th

e in

tens

ity o

f pov

erty

-Nat

iona

l Rur

al H

ealth

Mis

sion

(N

RHM

) pro

vide

qua

lity

heal

th c

are

to e

very

hou

seho

ld th

roug

h its

up

grad

ed h

ealth

infra

stru

ctur

e an

d pr

ovis

ion

of ro

und

the-

cloc

k he

alth

se

rvic

es

38St

ate

Varia

tions

In T

he O

ut-

OfP

ocke

t Spe

ndin

g Bu

rden

Fo

r Out

patie

nt M

enta

l Hea

lth

Trea

tmen

t

Zuve

kas,

S. H

2009

Am

eric

aO

rigin

alU

sing

dat

a fro

m th

e M

edic

al

Expe

nditu

re P

anel

Sur

vey

(MEP

S)-C

onsi

dera

tion

of p

olic

ies

rela

ted

to th

e m

edic

atio

ns th

at a

ccou

nt

for t

wo

third

s of

out

-of-p

ocke

t sp

endi

ng-M

anag

e co

stly

med

icat

ions

thro

ugh

polic

ies

such

as

tiere

d an

d re

stric

-tiv

e fo

rmul

arie

s, in

crea

sed

cost

sh

arin

g, s

tep

ther

apy,

and

prio

r au

thor

izat

ion

-Enc

oura

ge th

e us

e of

effe

ctiv

e ge

neric

med

icat

ions

, in

plac

e of

ex

pens

ive

bran

d na

me

med

ica-

tions

39H

ealth

car

e-se

ekin

g be

havi

our a

nd

out-

of-p

ocke

t pay

men

ts in

Tbi

lisi,

Geo

rgia

Got

sadz

e, G

2005

Geo

rgia

Orig

inal

2500

hou

seho

lds

Prio

ritiz

e pu

blic

fina

ncin

g of

ser

vice

s fo

r the

poo

r, in

par

ticul

ar th

roug

h am

endi

ng th

e Ba

sic

Bene

fit P

ack-

age

so th

at it

bet

ter r

eflec

ts th

e ne

eds

of th

e po

or;

-Pro

mot

e th

e qu

ality

and

util

izat

ion

of p

rimar

y ca

re s

ervi

ces;

-Add

ress

the

issu

e of

ratio

nal d

rug

use;

-Con

side

r mob

ilizi

ng o

ut-o

f-poc

ket

paym

ents

on

a pr

e-pa

id b

asis

th

roug

h fo

rmal

or c

omm

unity

ba

sed

risk

pool

ing

sche

mes


Tabl

e 5

(con

tinue

d)

NTi

tleA

utho

rYe

arPl

ace

Type

Part

icip

ants

Resu

lts

40Ph

ysic

ian

Stra

tegi

es to

Red

uce

Patie

nts’

Out

-of-p

ocke

t Pre

scrip

-tio

n Co

sts

Ale

xand

er, G

. C20

05U

nite

d St

ates

Orig

inal

Inve

stig

atio

n70

0 G

ener

al in

tern

ists

and

700

ca

rdio

logi

sts

from

the

Am

eric

an

Med

ical

Ass

ocia

tion

-Phy

sici

ans

shou

ld d

evel

op th

e ha

bit

of u

sing

brie

f jus

t-in

-tim

e in

terv

en-

tions

at t

he p

oint

of p

resc

riptio

n or

derin

g-P

hysi

cian

s sh

ould

dev

elop

the

habi

t of

usi

ng b

rief j

ust-

in-t

ime

inte

rven

-tio

ns a

t the

poi

nt o

f pre

scrip

tion

orde

ring

-Sw

itch

from

a b

rand

-nam

e to

a

gene

ric d

rug

-Giv

e th

e pa

tient

offi

ce s

ampl

es-C

ritic

ally

revi

ew m

edic

atio

n lis

t an

d di

scon

tinue

non

esse

ntia

l m

edic

ines

-Sw

itch

to a

diff

eren

t bra

nd-n

ame

drug

with

in th

e sa

me

drug

cla

ss-P

resc

ribe

a hi

gher

dos

e of

med

icin

e an

d te

ll th

e pa

tient

to s

plit

the

tabl

ets

-Ref

er th

e pa

tient

to a

pha

rmac

euti-

cal c

ompa

ny a

ssis

tanc

e pr

ogra

m-R

ecom

men

d th

e us

e of

an

over

-the

-co

unte

r med

icin

e as

a s

ubst

itute

-Ref

er th

e pa

tient

to a

pub

lic a

id

agen

cy o

r soc

ial w

orke

r


AcknowledgementsAuthors would like to thank Shiraz University of Medical Sciences (SUMS) for financial support of the research.

Authors’ contributionsFSJ and PB did the search and screaning and data extraction. SD raised the research idea and supervises all phase of the research. All authors have equal contribution in drafting and reviewing the manuscript. All authors have read and approved the final manuscript.

FundingThe study has been funded by Shiraz University of Medical Sciences (SUMS) under the code of 23113.

Availability of data and materialsData of this research is available and could be sent upon contact with the corresponding author.

Declarations

Ethics approval and consent to participateThe study protocol has been approved by ethics committee of Shiraz Univer-sity of Medical Sciences under the code of IR.SUMS.REC.1400.030.

Consent for publicationNot applicable.

Competing interestsThe authors declare they have no competing interest regarding to this research.

Author details1 Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. 2 Health Human Resources Research Center, School of Health Manage-ment and Information Sciences, Shiraz University of Medical Sciences, Shiraz, Iran.

Received: 6 June 2021 Accepted: 28 July 2021

References 1. World Health Organization. Countries are spending more on health, but

people are still paying too much out of their own pockets. 2019. 2. Kalantari H, Davari M, Akbari M, Hejazi SM, Kalantari M, Zakerin S, et al.

The estimation of direct medical costs of treating patients with chronic hepatitis B and C in iran. Int J Prev Med. 2012;3(3):191.

3. Tarricone R. Cost-of-illness analysis: what room in health economics? Health Policy. 2006;77(1):51–63.

4. Sriram S, Khan MM. Effect of health insurance program for the poor on out-of-pocket inpatient care cost in India: evidence from a nationally rep-resentative cross-sectional survey. BMC Health Serv Res. 2020;20(1):1–21.

5. Garg CC, Karan AK. Reducing out-of-pocket expenditures to reduce poverty: a disaggregated analysis at rural-urban and state level in India. Health Policy Plan. 2009;24(2):116–28.

6. Hunter WG, Zhang CZ, Hesson A, Davis JK, Kirby C, Williamson LD, et al. What strategies do physicians and patients discuss to reduce out-of-pocket costs? Analysis of cost-saving strategies in 1755 outpatient clinic visits. Med Decis Making. 2016;36(7):900–10.

7. Baji P, Pavlova M, Gulácsi L, Groot W. Changes in equity in out-of-pocket payments during the period of health care reforms: evidence from Hun-gary. Int J Equity Health. 2012;11(1):36.

8. World Bank: People Spend Half a Trillion Dollars Out-Of-Pocket on Health in Developing Countries Annually. 2019.

9. World Health Organization.Global spending on health: a world in transi-tion. 2019.

10. Wagstaff A, Eozenou P, Smitz M. Out-of-pocket expenditures on health: a global stocktake. World Bank Res Obs. 2020;35(2):123–57.

11. Tabari-Khomeiran R, Delavari S, Rezaei S, Rad EH, Shahmoradi M. The effect of Iranian health system reform plan on payments and costs of coronary artery bypass surgery in private hospitals of Iran. Int J Hum Rights Healthc. 2019;12(3):208–14.

12. World Health Organization. Developing a national health financing strategy. 2017.

13. Schofield D, Cunich M, Shrestha R, Passey M, Veerman L, Tanton R, et al. The indirect costs of ischemic heart disease through lost productive life years for Australia from 2015 to 2030: results from a microsimulation model. BMC Public Health. 2019;19(1):1–13.

14. Kircher SM, Meeker CR, Nimeiri H, Geynisman DM, Zafar SY, Shankaran V, et al. The parity paradigm: can legislation help reduce the cost burden of oral anticancer medications? Value Health. 2016;19(1):88–98.

15. Ergo A, Htoo TS, Badiani-Magnusson R, Royono R. A new hope: from neglect of the health sector to aspirations for Universal Health Coverage in Myanmar. Health Policy Plan. 2019;34(Supplement_1):i38–46.

16. Meda IB, Baguiya A, Ridde V, Ouédraogo HG, Dumont A, Kouanda S. Out-of-pocket payments in the context of a free maternal health care policy in Burkina Faso: a national cross-sectional survey. Heal Econ Rev. 2019;9(1):11.

17. Heydari M, Mehraeen M, Joulaei H. Over Medication and Waste of Resources in Physicians’ Prescriptions: A Cross Sectional Study in South-western Iran. Shiraz E Med J. 2020. https:// doi. org/ 10. 5812/ semj. 97662.

18. Dou G, Wang Q, Ying X. Reducing the medical economic burden of health insurance in China: achievements and challenges. Biosci Trends. 2018;12(3):215–9.

19. Molla AA, Chi C, Mondaca ALN. Predictors of high out-of-pocket health-care expenditure: an analysis using Bangladesh household income and expenditure survey, 2010. BMC Health Serv Res. 2017;17(1):94.

20. Zuvekas SH, Meyerhoefer CD. State variations in the out-of-pocket spending burden for outpatient mental health treatment. Health Aff. 2009;28(3):713–22.

21. Orenstein L, Chetrit A, Oberman B, Benderly M, Kalter-Leibovici O. Factors associated with disparities in out-of-pocket expenditure on dental care: results from two cross-sectional national surveys. Isr J Health Policy Res. 2020;9(1):1–17.

22. Sarnak DO, Squires D, Kuzmak G, Bishop S. Paying for prescription drugs around the world: why is the US an outlier? Issue Br. 2017;2017:1–14.

23. Miyawaki A, Kobayashi Y. Effect of a medical subsidy on health service uti-lization among schoolchildren: a community-based natural experiment in Japan. Health Policy. 2019;123(4):353–9.

24. Gotsadze G, Bennett S, Ranson K, Gzirishvili D. Health care-seeking behav-iour and out-of-pocket payments in Tbilisi, Georgia. Health Policy Plan. 2005;20(4):232–42.

25. Starner CI, Alexander GC, Bowen K, Qiu Y, Wickersham PJ, Gleason PJ. Spe-cialty drug coupons lower out-of-pocket costs and may improve adher-ence at the risk of increasing premiums. Health Aff. 2014;33(10):1761–9.

26. Becker NV, Polsky D. Women saw large decrease in out-of-pocket spend-ing for contraceptives after ACA mandate removed cost sharing. Health Aff. 2015;34(7):1204–11.

27. Finer LB, Sonfield A, Jones RK. Changes in out-of-pocket payments for contraception by privately insured women during implementation of the federal contraceptive coverage requirement. Contraception. 2014;89(2):97–102.

28. Bernabé E, Masood M, Vujicic M. The impact of out-of-pocket payments for dental care on household finances in low and middle income coun-tries. BMC Public Health. 2017;17(1):109.

29. Erus B, Aktakke N. Impact of healthcare reforms on out-of-pocket health expenditures in Turkey for public insurees. Eur J Health Econ. 2012;13(3):337–46.

30. Rahman MM, Gilmour S, Saito E, Sultana P, Shibuya K. Health-related financial catastrophe, inequality and chronic illness in Bangladesh. PLoS One. 2013;8(2):e56873.

31. Kastor A, Mohanty SK. Disease-specific out-of-pocket and catastrophic health expenditure on hospitalization in India: Do Indian households face distress health financing? PLoS One. 2018;13(5):e0196106.

32. Bose M, Dutta A. Health financing strategies to reduce out-of-pocket burden in India: a comparative study of three states. BMC Health Serv Res. 2018;18(1):830.

https://doi.org/10.5812/semj.97662


• fast, convenient online submission

•

thorough peer review by experienced researchers in your field

• rapid publication on acceptance

• support for research data, including large and complex data types

•

gold Open Access which fosters wider collaboration and increased citations

maximum visibility for your research: over 100M website views per year •

At BMC, research is always in progress.

Learn more biomedcentral.com/submissions

Ready to submit your researchReady to submit your research ? Choose BMC and benefit from: ? Choose BMC and benefit from:

33. Jian W, Lu M, Chan KY, Poon AN, Han W, Hu M, et al. Payment reform pilot in Beijing hospitals reduced expenditures and out-of-pocket payments per admission. Health Aff. 2015;34(10):1745–52.

34. Rahman MM, Zhang C, Swe KT, Rahman MS, Islam MR, Kamrujjaman M, et al. Disease-specific out-of-pocket healthcare expenditure in urban Bangladesh: a Bayesian analysis. PLoS One. 2020;15(1):e0227565.

35. Khan JA, Ahmed S, Sultana M, Sarker AR, Chakrovorty S, Rahman MH, et al. The effect of a community-based health insurance on the out-of-pocket payments for utilizing medically trained providers in Bangladesh. Int Health. 2020;12(4):287–98.

36. Tobe M, Stickley A, del Rosario Jr RB, Shibuya K. Out-of-pocket medi-cal expenses for inpatient care among beneficiaries of the National Health Insurance Program in the Philippines. Health Policy Plan. 2013;28(5):536–48.

37. Aryeetey GC, Westeneng J, Spaan E, Jehu-Appiah C, Agyepong IA, Baltussen R. Can health insurance protect against out-of-pocket and catastrophic expenditures and also support poverty reduction? Evidence from Ghana’s National Health Insurance Scheme. Int J Equity Health. 2016;15(1):116.

38. Rout SK, Choudhury S. Does public health system provide adequate financial risk protection to its clients? Out of pocket expenditure on inpatient care at secondary level public health institutions: causes and determinants in an eastern Indian state. Int J Health Plann Manage. 2018;33(2):e500–11.

39. McIntyre WF, Belesiotis P, McClure GR, Demers C, Chahill G, Hayes A, et al. Strategies to reduce out-of-pocket medication costs for Canadians living with heart failure. Cardiovasc Drugs Ther. 2020. https:// doi. org/ 10. 1007/ s10557- 020- 07046-1.

40. Hill SC. Individual insurance benefits to be available under health reform would have cut out-of-pocket spending in 2001–08. Health Aff. 2012;31(6):1349–56.

41. Aji B, De Allegri M, Souares A, Sauerborn R. The impact of health insur-ance programs on out-of-pocket expenditures in Indonesia: an increase or a decrease? Int J Environ Res Public Health. 2013;10(7):2995–3013.

42. Shahrawat R, Rao KD. Insured yet vulnerable: out-of-pocket payments and India’s poor. Health Policy Plan. 2012;27(3):213–21.

43. Baird KE. The financial burden of out-of-pocket expenses in the United States and Canada: how different is the United States? SAGE Open Med. 2016;4:2050312115623792.

44. Loh P, Sabesan S, Allen D, Caldwell P, Mozer R, Komesaroff PA, et al. Practical aspects of telehealth: financial considerations. Intern Med J. 2013;43(7):829–34.

45. Alexander GC, Casalino LP, Meltzer DO. Physician strategies to reduce patients’ out-of-pocket prescription costs. Arch Intern Med. 2005;165(6):633–6.

46. Cutler TW, Stebbins MR, Smith AR, Patel RA, Lipton HL. Promoting access and reducing expected out-of-pocket prescription drug costs for vulner-able medicare beneficiaries: a pharmacist-directed model. Med Care. 2011;1:343–7.

47. Dodson SE, Ruisinger JF, Howard PA, Hare SE, Barnes BJ. Community pharmacy-based medication therapy management services: financial impact for patients. Pharm Pract. 2012;10(3):119.

48. Atella V, Brugiavini A, Pace N. The health care system reform in China: effects on out-of-pocket expenses and saving. China Econ Rev. 2015;34:182–95.

49. Meng Z, Ma Y, Song S, Li Y, Wang D, Si Y, et al. Economic implications of chinese diagnosis-related group-based payment systems for critically Ill patients in ICUs. Crit Care Med. 2020;48(7):e565–73.

50. Miljeteig I, Defaye FB, Wakim P, Desalegn DN, Berhane Y, Norheim OF, et al. Financial risk protection at the bedside: How Ethiopian physi-cians try to minimize out-of-pocket health expenditures. PLoS One. 2019;14(2):e0212129.

51. Harvey SC, Vegesna A, Mass S, Clarke J, Skoufalos A. Understanding patient options, utilization patterns, and burdens associated with breast cancer screening. J Womens Health. 2014;23(S1):S-3-S-9.

52. World Health Organization. The world health report 2000: health systems: improving performance. Geneva: World Health Organization, 2000.

53. Asefzadeh S, Alijanzadeh M, Peyravian F. Out of pocket expenditures for outpatient clinics in teaching hospitals. Payesh. 2014;13(3):267–76.

54. Kavosi Z, Lankarani KB, Dehnavieh R, Ghorbanian A. Influential factors of out of pocket payments for health care in Iran: A foresight approach using the cross impact analysis. J Pak Med Assoc. 2020;70(11):1918–26.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims in pub-lished maps and institutional affiliations.

https://doi.org/10.1007/s10557-020-07046-1

https://doi.org/10.1007/s10557-020-07046-1

Documents

Strategies for reducing out of pocket payments in the