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How Important Is Income in Explaining Avoidance of Care Due to Cost-Sharing Payments? Results From a Mixed Methods Sequential Explanatory Study.


 Background

The avoidance of healthcare by patients because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to the avoidance of healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better.
Methods

Survey data was collected from a Dutch panel of frequent users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics with regard to the avoidance, i.e., personal characteristics, health, skills and financial situation. Semi-structured interviews (n = 5) were conducted with those who had avoided healthcare. The verbatim transcribed interviews were thematically analyzed.
Results

Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had avoided healthcare because of the deductible requirement. Dominance analyses revealed that an individual’s financial leeway contributed the most (34.8%) to the model’s overall McFadden’s pseudo-R2 (i.e., 0.12), followed by income (25.6%), age (19.6%) and sense of mastery (8.9%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes: (1) the financial reasons and (2) personal considerations that affected the decision whether to use healthcare, (3) the perceived uncertainty in payments due to the complex design of cost-sharing programs, and (4) whether the use of healthcare was perceived as compulsory. Furthermore, ‘avoidance of healthcare’ seemed to have a negative connotation.
Conclusion

Our findings show that avoidance of healthcare depends on various factors including income, and imply that focusing solely on lowering cost-sharing payments for certain individuals will only partly reduce this avoidance. Our study underlines the need for a broader perspective in the design of cost-sharing programs.