Impact of Cost Sharing on Emergency Service Utilization in Health Insurance Plans: A Systematic Review_Chinese Journal of Evidence-Based Medicine

Authors：

ZHANG Guojie ,  JIA Liying , YUAN Beibei , YANG Bingyi , MA Dongping , ZHAO Shichao , YU Haining , CHANG Jie

Centre for Health Management and Policy, Shandong University, Key Lab for Health Economics and Policy Research of the Ministry of Health, Jinan 250012, China;

Corresponding?author：

JIA Liying, Email: lyjia@sdu.edu.cn

Keywords：

Cost sharing; Copayment; Emergency; Systematic review

DOI：

10.7507/1672-2531.20130004

Video：

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Objective 　To describe and analyze both the direct impact of emergency service (ES) cost sharing and the indirect impact of drug cost sharing on emergency service utilization (ESU) in health insurance plans.
Methods 　The author searched18 electronic databases which were in the evidence-based, public health, economic and social categories, respectively, 2 grey literature review resources and Google search engine, and the retrieval time was from June 21st, 2011 to September 19th, 2011. According to the inclusion criteria, data screening and extraction were conducted by two reviewers independently, and the differences were discussed by a third person or a review group. The theme analysis was adopted to systematically analyze both the direct and indirect impacts of cost sharing on ESU. Additionally, the side effects were analyzed too.
Results 　Among total 22 studies included, 13 described the direct impact of ESU cost sharing, while the other 9 referred to the indirect impact of drug cost sharing. There were mainly 5 categories of health plans involved in. The results showed that, ESU could respond to the cost sharing: ESU decreased when the proportion of copayment increased, and vice versa. The increase of drug copayment impaired the use of essential drugs and finally increased ESU. However, a modest ES copayment decreased the irrational ESU rather than the rational ESU.
Conclusion 　To the insured, the increase of ES cost sharing would not decrease the rational ESU and has no adverse events, while the increase of drug cost sharing would lead to some adverse events such as the increase of ESU. To the uninsured, the impact of cost sharing needs to be further disccussed. So this review suggests, the proper ES self-payment should be introduced into the health insurance plans according to local economic status, resident income, etc.; in addition, the drug self-payment ratio should be determined cautiously.

Citation： ZHANG Guojie,JIA Liying,YUAN Beibei,YANG Bingyi,MA Dongping,ZHAO Shichao,YU Haining,CHANG Jie. Impact of Cost Sharing on Emergency Service Utilization in Health Insurance Plans: A Systematic Review. Chinese Journal of Evidence-Based Medicine, 2013, 13(1): 5-12. doi: 10.7507/1672-2531.20130004 Copy

1.	Newhouse JP. Cost Sharing for Medical Care Services. RAND Corporation, 1984.
2.	Rice T, Morrison KR. Patient cost sharing for medical services: a review of the literature and implications for health care reform. Med Care Rev, 1994, 51(3): 235-287.
3.	Swartz K. Cost-sharing: effects on spending and outcomes. Synth Proj Res Synth Rep. Harvard School of Public Health, 2010.
4.	Rubin RJ, Mendelson DN. Cost sharing in health insurance. N Engl J Med, 1995, 333(11): 733-734.
5.	Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med, 1981, 305(25): 1501-1507.
6.	Newhouse JP. Free for All? Lessons From the RAND Health Insurance Experiment. Cambridge, Mass: Harvard University Press, 1996.
7.	Roblin DW, Platt R, Goodman MJ, et al. Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much? Med Care, 2005, 43(10): 951-959.
8.	Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
9.	Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med, 1995, 332(17): 1138-1143.
10.	Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
11.	Lowe RA, Fu R, Ong ET, et al. Community characteristics affecting emergency department use by Medicaid enrollees. Med Care, 2009, 47(1): 15-22.
12.	Lowe RA, Localio AR, Schwarz DF, et al. Association between primary care practice characteristics and emergency department use in a Medicaid managed care organization. Med Care, 2005, 43(8): 792-800.
13.	Richardson LD, Hwang U. Access to care: a review of the emergency medicine literature. Acad Emerg Med, 2001, 8(11): 1030-1036.
14.	Andrulis DP, Kellermann AL, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med, 1991, 20(9): 980-986.
15.	Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood), 1994, 13(5): 162-171.
16.	Wright BJ, Carlson MJ, Allen H, et al. Raising premiums and other costs for Oregon health plan enrollees drove many to drop out. Health Aff (Millwood). 2010, 29(12): 2311-2316.
17.	Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl J Med, 1996, 334(10): 635-641.
18.	Billings J, Parikh N, Mijanovich T. Emergency room use: the New York story. Issue Brief (Commonw Fund), 2000, (434): 1-12.
19.	Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a survey of Bronx patients. Issue Brief (Commonw Fund), 2000, (435): 1-5.
20.	Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a substitute for primary care? Issue Brief (Commonw Fund), 2000, (433): 1-5.
21.	Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
22.	Yang W, Kahler KH, Fellers T, et al. Copayment level, treatment persistence, and healthcare utilization in hypertension patients treated with single-pill combination therapy. J Med Econ, 2011, 14(3): 267-278.
23.	Dormuth CR, Maclure M, Glynn RJ, et al. Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications. Clin Ther, 2008, 30: 1038-1050.
24.	Austvoll-Dahlgren A, Aaserud M, Vist G, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database Syst Rev, 2008, (1): CD007017.
25.	O’Grady KF, Manning WG, Newhouse JP, et al. The impact of cost sharing on emergency department use. N Engl J Med, 1985, 313(8): 484-490.
26.	Hsu J, Reed M, Brand R, et al. Cost-sharing: patient knowledge and effects on seeking emergency department care. Med Care, 2004, 42(3): 290-296.
27.	Hsu J, Price M, Brand R, et al. Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study. Health Serv Res, 2006, 41(5): 1801-1820.
28.	Reed M, Fung V, Brand R, et al. Care-seeking behavior in response to emergency department copayments. Med Care, 2005, 43(8): 810-816.
29.	Lowe RA, McConnell KJ, Fu R, et al. Changes in access to primary care for Medicaid beneficiaries and the uninsured: the emergency department perspective. Am J Emerg Med, 2006, 24(1): 33-37.
30.	Lowe RA, McConnell KJ, Vogt ME, et al. Impact of Medicaid cutbacks on emergency department use: the Oregon experience. Ann Emerg Med, 2008, 52(6): 626-634.
31.	Lowe RA, Fu R, Gallia CA. Impact of policy changes on emergency department use by Medicaid enrollees in Oregon. Med Care, 2010, 48(7): 619-627.
32.	Wallace NT, McConnell KJ, Gallia CA, et al. How effective are copayments in reducing expenditures for low-income adult Medicaid beneficiaries? Experience from the Oregon health plan. Health Serv Res, 2008, 43(2): 515-530.
33.	Wharam JF, Landon BE, Galbraith AA, et al. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA, 2007, 297(10): 1093-1102.
34.	Waters TM, Chang CF, Cecil WT, et al. Impact of high-deductible health plans on health care utilization and costs. Health Serv Res, 2011, 46(1Pt1): 155-172.
35.	Magid DJ, Koepsell TD, Every NR, et al. Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction. N Engl J Med, 1997, 336(24): 1722-1729.
36.	Lischko AM. Cost sharing: do employees understand cost sharing and do increases in cost sharing really have an impact on the utilization of health care services? Boston: Boston University, 2008.
37.	Dormuth CR, Neumann P, Maclure M, et al. Effects of prescription coinsurance and income-based deductibles on net health plan spending for older users of inhaled medications. Med Care, 2009, 47(5): 508-516.
38.	Gibson TB, Mark TL, Axelsen K, et al. Impact of statin copayments on adherence and medical care utilization and expenditures. Am J Manag Care, 2006, 12 Spec no.: SP11-19.
39.	Gibson TB, Song X, Alemayehu B, et al. Cost sharing, adherence, and health outcomes in patients with diabetes. Am J Manag Care, 2010, 16(8): 589-600.
40.	Fairman KA, Motheral BR, Henderson RR. Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. ClinTher, 2003, 25(12): 3147-3161.
41.	Nair KV, Miller K, Park J, et al. Prescription co-pay reduction program for diabetic employees. Popul Health Manag, 2010, 13(5): 235-245.
42.	Goldman DP, Joyce GF, Karaca-Mandic P. Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. Am J Manag Care, 2006, 12(1): 21-28.
43.	Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. Effects of limiting Medicaid drug reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med, 1994, 331(10): 650-655.
44.	Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
45.	Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. N Engl J Med, 1983, 309(23): 1426-1434.
46.	Zweifel P, Manning WG. Moral Hazard and Consumer Incentives in Health Care. In: Culyer AJ, Newhouse JP. Handbook of Health Economics edition 1, 2000: 409-459.

1. Newhouse JP. Cost Sharing for Medical Care Services. RAND Corporation, 1984.
2. Rice T, Morrison KR. Patient cost sharing for medical services: a review of the literature and implications for health care reform. Med Care Rev, 1994, 51(3): 235-287.
3. Swartz K. Cost-sharing: effects on spending and outcomes. Synth Proj Res Synth Rep. Harvard School of Public Health, 2010.
4. Rubin RJ, Mendelson DN. Cost sharing in health insurance. N Engl J Med, 1995, 333(11): 733-734.
5. Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med, 1981, 305(25): 1501-1507.
6. Newhouse JP. Free for All? Lessons From the RAND Health Insurance Experiment. Cambridge, Mass: Harvard University Press, 1996.
7. Roblin DW, Platt R, Goodman MJ, et al. Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations: how much is too much? Med Care, 2005, 43(10): 951-959.
8. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
9. Blustein J. Medicare coverage, supplemental insurance, and the use of mammography by older women. N Engl J Med, 1995, 332(17): 1138-1143.
10. Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
11. Lowe RA, Fu R, Ong ET, et al. Community characteristics affecting emergency department use by Medicaid enrollees. Med Care, 2009, 47(1): 15-22.
12. Lowe RA, Localio AR, Schwarz DF, et al. Association between primary care practice characteristics and emergency department use in a Medicaid managed care organization. Med Care, 2005, 43(8): 792-800.
13. Richardson LD, Hwang U. Access to care: a review of the emergency medicine literature. Acad Emerg Med, 2001, 8(11): 1030-1036.
14. Andrulis DP, Kellermann AL, Hintz EA, et al. Emergency departments and crowding in United States teaching hospitals. Ann Emerg Med, 1991, 20(9): 980-986.
15. Baker LC, Baker LS. Excess cost of emergency department visits for nonurgent care. Health Aff (Millwood), 1994, 13(5): 162-171.
16. Wright BJ, Carlson MJ, Allen H, et al. Raising premiums and other costs for Oregon health plan enrollees drove many to drop out. Health Aff (Millwood). 2010, 29(12): 2311-2316.
17. Selby JV, Fireman BH, Swain BE. Effect of a copayment on use of the emergency department in a health maintenance organization. N Engl J Med, 1996, 334(10): 635-641.
18. Billings J, Parikh N, Mijanovich T. Emergency room use: the New York story. Issue Brief (Commonw Fund), 2000, (434): 1-12.
19. Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a survey of Bronx patients. Issue Brief (Commonw Fund), 2000, (435): 1-5.
20. Billings J, Parikh N, Mijanovich T. Emergency department use in New York City: a substitute for primary care? Issue Brief (Commonw Fund), 2000, (433): 1-5.
21. Tamblyn R, Laprise R, Hanley JA, et al. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. JAMA, 2001, 285(4): 421-429.
22. Yang W, Kahler KH, Fellers T, et al. Copayment level, treatment persistence, and healthcare utilization in hypertension patients treated with single-pill combination therapy. J Med Econ, 2011, 14(3): 267-278.
23. Dormuth CR, Maclure M, Glynn RJ, et al. Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications. Clin Ther, 2008, 30: 1038-1050.
24. Austvoll-Dahlgren A, Aaserud M, Vist G, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. Cochrane Database Syst Rev, 2008, (1): CD007017.
25. O’Grady KF, Manning WG, Newhouse JP, et al. The impact of cost sharing on emergency department use. N Engl J Med, 1985, 313(8): 484-490.
26. Hsu J, Reed M, Brand R, et al. Cost-sharing: patient knowledge and effects on seeking emergency department care. Med Care, 2004, 42(3): 290-296.
27. Hsu J, Price M, Brand R, et al. Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study. Health Serv Res, 2006, 41(5): 1801-1820.
28. Reed M, Fung V, Brand R, et al. Care-seeking behavior in response to emergency department copayments. Med Care, 2005, 43(8): 810-816.
29. Lowe RA, McConnell KJ, Fu R, et al. Changes in access to primary care for Medicaid beneficiaries and the uninsured: the emergency department perspective. Am J Emerg Med, 2006, 24(1): 33-37.
30. Lowe RA, McConnell KJ, Vogt ME, et al. Impact of Medicaid cutbacks on emergency department use: the Oregon experience. Ann Emerg Med, 2008, 52(6): 626-634.
31. Lowe RA, Fu R, Gallia CA. Impact of policy changes on emergency department use by Medicaid enrollees in Oregon. Med Care, 2010, 48(7): 619-627.
32. Wallace NT, McConnell KJ, Gallia CA, et al. How effective are copayments in reducing expenditures for low-income adult Medicaid beneficiaries? Experience from the Oregon health plan. Health Serv Res, 2008, 43(2): 515-530.
33. Wharam JF, Landon BE, Galbraith AA, et al. Emergency department use and subsequent hospitalizations among members of a high-deductible health plan. JAMA, 2007, 297(10): 1093-1102.
34. Waters TM, Chang CF, Cecil WT, et al. Impact of high-deductible health plans on health care utilization and costs. Health Serv Res, 2011, 46(1Pt1): 155-172.
35. Magid DJ, Koepsell TD, Every NR, et al. Absence of association between insurance copayments and delays in seeking emergency care among patients with myocardial infarction. N Engl J Med, 1997, 336(24): 1722-1729.
36. Lischko AM. Cost sharing: do employees understand cost sharing and do increases in cost sharing really have an impact on the utilization of health care services? Boston: Boston University, 2008.
37. Dormuth CR, Neumann P, Maclure M, et al. Effects of prescription coinsurance and income-based deductibles on net health plan spending for older users of inhaled medications. Med Care, 2009, 47(5): 508-516.
38. Gibson TB, Mark TL, Axelsen K, et al. Impact of statin copayments on adherence and medical care utilization and expenditures. Am J Manag Care, 2006, 12 Spec no.: SP11-19.
39. Gibson TB, Song X, Alemayehu B, et al. Cost sharing, adherence, and health outcomes in patients with diabetes. Am J Manag Care, 2010, 16(8): 589-600.
40. Fairman KA, Motheral BR, Henderson RR. Retrospective, long-term follow-up study of the effect of a three-tier prescription drug copayment system on pharmaceutical and other medical utilization and costs. ClinTher, 2003, 25(12): 3147-3161.
41. Nair KV, Miller K, Park J, et al. Prescription co-pay reduction program for diabetic employees. Popul Health Manag, 2010, 13(5): 235-245.
42. Goldman DP, Joyce GF, Karaca-Mandic P. Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy. Am J Manag Care, 2006, 12(1): 21-28.
43. Soumerai SB, McLaughlin TJ, Ross-Degnan D, et al. Effects of limiting Medicaid drug reimbursement benefits on the use of psychotropic agents and acute mental health services by patients with schizophrenia. N Engl J Med, 1994, 331(10): 650-655.
44. Soumerai SB, Ross-Degnan D, Avorn J, et al. Effects of Medicaid drug payment limits on admission to hospitals and nursing homes. N Engl J Med, 1991, 325(15): 1072-1077.
45. Brook RH, Ware JE, Rogers WH, et al. Does free care improve adults’ health? Results from a randomized controlled trial. N Engl J Med, 1983, 309(23): 1426-1434.
46. Zweifel P, Manning WG. Moral Hazard and Consumer Incentives in Health Care. In: Culyer AJ, Newhouse JP. Handbook of Health Economics edition 1, 2000: 409-459.

Chinese Journal of Evidence-Based Medicine

Impact of Cost Sharing on Emergency Service Utilization in Health Insurance Plans: A Systematic Review

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