Browsing by Subject "Healthcare Financing"

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    Funding allocation to surgery in low and middle-income countries: a retrospective analysis of contributions from the USA.
    (BMJ open, 2015-11-09) Gutnik, Lily; Dieleman, Joseph; Dare, Anna J; Ramos, Margarita S; Riviello, Robert; Meara, John G; Yamey, Gavin; Shrime, Mark G
    OBJECTIVE:The funds available for global surgical delivery, capacity building and research are unknown and presumed to be low. Meanwhile, conditions amenable to surgery are estimated to account for nearly 30% of the global burden of disease. We describe funds given to these efforts from the USA, the world's largest donor nation. DESIGN:Retrospective database review. US Agency for International Development (USAID), National Institute of Health (NIH), Foundation Center and registered US charitable organisations were searched for financial data on any organisation giving exclusively to surgical care in low and middle income countries (LMICs). For USAID, NIH and Foundation Center all available data for all years were included. The five recent years of financial data per charitable organisation were included. All nominal dollars were adjusted for inflation by converting to 2014 US dollars. SETTING:USA. PARTICIPANTS:USAID, NIH, Foundation Center, Charitable Organisations. PRIMARY AND SECONDARY OUTCOME MEASURES:Cumulative funds appropriated to global surgery. RESULTS:22 NIH funded projects (totalling $31.3 million) were identified, primarily related to injury and trauma. Six relevant USAID projects were identified-all obstetric fistula care totalling $438 million. A total of $105 million was given to universities and charitable organisations by US foundations for 12 different surgical specialties. 95 US charitable organisations representing 14 specialties totalled revenue of $2.67 billion and expenditure of $2.5 billion. CONCLUSIONS AND RELEVANCE:Current funding flows to surgical care in LMICs are poorly understood. US funding predominantly comes from private charitable organisations, is often narrowly focused and does not always reflect local needs or support capacity building. Improving surgical care, and embedding it within national health systems in LMICs, will likely require greater financial investment. Tracking funds targeting surgery helps to quantify and clarify current investments and funding gaps, ensures resources materialise from promises and promotes transparency within global health financing.
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    Improving rational use of ACTs through diagnosis-dependent subsidies: Evidence from a cluster-randomized controlled trial in western Kenya.
    (PLoS medicine, 2018-07-17) Prudhomme O'Meara, Wendy; Menya, Diana; Laktabai, Jeremiah; Platt, Alyssa; Saran, Indrani; Maffioli, Elisa; Kipkoech, Joseph; Mohanan, Manoj; Turner, Elizabeth L
    BACKGROUND:More than half of artemisinin combination therapies (ACTs) consumed globally are dispensed in the retail sector, where diagnostic testing is uncommon, leading to overconsumption and poor targeting. In many malaria-endemic countries, ACTs sold over the counter are available at heavily subsidized prices, further contributing to their misuse. Inappropriate use of ACTs can have serious implications for the spread of drug resistance and leads to poor outcomes for nonmalaria patients treated with incorrect drugs. We evaluated the public health impact of an innovative strategy that targets ACT subsidies to confirmed malaria cases by coupling free diagnostic testing with a diagnosis-dependent ACT subsidy. METHODS AND FINDINGS:We conducted a cluster-randomized controlled trial in 32 community clusters in western Kenya (population approximately 160,000). Eligible clusters had retail outlets selling ACTs and existing community health worker (CHW) programs and were randomly assigned 1:1 to control and intervention arms. In intervention areas, CHWs were available in their villages to perform malaria rapid diagnostic tests (RDTs) on demand for any individual >1 year of age experiencing a malaria-like illness. Malaria RDT-positive individuals received a voucher for a discount on a quality-assured ACT, redeemable at a participating retail medicine outlet. In control areas, CHWs offered a standard package of health education, prevention, and referral services. We conducted 4 population-based surveys-at baseline, 6 months, 12 months, and 18 months-of a random sample of households with fever in the last 4 weeks to evaluate predefined, individual-level outcomes. The primary outcome was uptake of malaria diagnostic testing at 12 months. The main secondary outcome was rational ACT use, defined as the proportion of ACTs used by test-positive individuals. Analyses followed the intention-to-treat principle using generalized estimating equations (GEEs) to account for clustering with prespecified adjustment for gender, age, education, and wealth. All descriptive statistics and regressions were weighted to account for sampling design. Between July 2015 and May 2017, 32,404 participants were tested for malaria, and 10,870 vouchers were issued. A total of 7,416 randomly selected participants with recent fever from all 32 clusters were surveyed. The majority of recent fevers were in children under 18 years (62.9%, n = 4,653). The gender of enrolled participants was balanced in children (49.8%, n = 2,318 boys versus 50.2%, n = 2,335 girls), but more adult women were enrolled than men (78.0%, n = 2,139 versus 22.0%, n = 604). At baseline, 67.6% (n = 1,362) of participants took an ACT for their illness, and 40.3% (n = 810) of all participants took an ACT purchased from a retail outlet. At 12 months, 50.5% (n = 454) in the intervention arm and 43.4% (n = 389) in the control arm had a malaria diagnostic test for their recent fever (adjusted risk difference [RD] = 9 percentage points [pp]; 95% CI 2-15 pp; p = 0.015; adjusted risk ratio [RR] = 1.20; 95% CI 1.05-1.38; p = 0.015). By 18 months, the ARR had increased to 1.25 (95% CI 1.09-1.44; p = 0.005). Rational use of ACTs in the intervention area increased from 41.7% (n = 279) at baseline to 59.6% (n = 403) and was 40% higher in the intervention arm at 18 months (ARR 1.40; 95% CI 1.19-1.64; p < 0.001). While intervention effects increased between 12 and 18 months, we were not able to estimate longer-term impact of the intervention and could not independently evaluate the effects of the free testing and the voucher on uptake of testing. CONCLUSIONS:Diagnosis-dependent ACT subsidies and community-based interventions that include the private sector can have an important impact on diagnostic testing and population-wide rational use of ACTs. Targeting of the ACT subsidy itself to those with a positive malaria diagnostic test may also improve sustainability and reduce the cost of retail-sector ACT subsidies. TRIAL REGISTRATION:ClinicalTrials.gov NCT02461628.
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    Online Crowdfunding Campaigns for Diabetes-Related Expenses.
    (Annals of internal medicine, 2023-07) Sloan, Caroline E; Campagna, Ada; Tu, Karissa; Doerstling, Steven; Davis, J Kelly; Ubel, Peter A
    Background: More than 40% of patients with diabetes in the United States have trouble paying their medical bills. Among patients with health-related financial hardship, 56% have delayed or foregone care (1). By one estimate, an insulin-dependent patient with insurance spends about $4800 annually on medications, physicians’ visits, supplies, hospitalizations, and lost wages, equivalent to 15% of the median U.S. per capita income (2). Crowdfunding is increasingly being used by patients struggling with medical costs (3). Crowdfunding campaigns can shed light on the types of expenses that patients with diabetes may struggle to afford (3). Objective: To leverage the rich real-world testimonies available in crowdfunding campaigns in order to characterize the financial challenges of patients with diabetes who seek fundraising support. Methods and Findings: We scraped a random sample of 89 645 active U.S. medical crowdfunding campaigns posted on GoFundMe from 2010 to August 2020, using a previously published natural-language algorithm (4). Campaigns were included if they were in English and requested money for a single person whose primary condition was diabetes. We randomly selected 350 of 807 campaigns that met inclusion criteria, with oversampling of type 1 diabetes campaigns to obtain roughly equal proportions of type 1 and non–type 1 diabetes campaigns and ensure a wide breadth of experiences. Campaigns described patients’ medical situations, expenses, and fundraising goals. We conducted a directed content analysis to evaluate for the presence of predetermined fundraising request categories (Table 1). Two authors double-coded the first 100 campaigns and 10% of the remaining 250 campaigns. Intercoder reliability using the Cohen κ coefficient was 0.67 or higher for all coding categories and direct medical expense subcategories. After exclusions, our final sample included 313 campaigns; 89% were posted during 2015 to 2020. The median fundraising goal was $10 000 (IQR, $4500 to $15 000), the median fundraising amount was $2600 (IQR, $1670 to $4760), and 14% of campaigns reached their goal. Table 2 highlights campaign characteristics overall and by stated diabetes type. One quarter of fundraisers reported having insurance; of these, 49% said their insurance covered their medical expenses but out-of-pocket costs were still too high. Almost half of direct medical expenses were not directly related to glucose control (99 of 206 [48%]). Only 6% requested money specifically for insulin. One fifth of campaigns (21%) requested money for diabetic alert dogs; almost all were campaigns for type 1 diabetes. Indirect medical expenses included lost wages, healthy food, moving to a new city to be closer to state-of-the-art medical care, car repairs to enable transportation to physicians’ appointments, personal trainers, home modifications to support new physical disabilities, and funeral expenses. Campaigns that were not specifically for type 1 diabetes (type 2 or unspecified) mentioned indirect medical expenses more often than campaigns for type 1 diabetes (63% vs. 34%). Discussion: Crowdfunding campaigns provide a window into the wide range of financial struggles that patients with diabetes may face. First, many aspects of diabetes care beyond insulin can be cost-prohibitive, including indirect expenses that clinicians may not be equipped to address. Although the Inflation Reduction Act’s cap on out-of-pocket costs for insulin is an important step in making care more affordable, policymakers should address other diabetes-related costs as well. Second, even people who have insurance use crowdfunding due to lack of coverage for certain expenses or unaffordable copayments. Third, 35% of patients with type 1 diabetes started fundraising campaigns for diabetic alert dogs, which cost about $15 000 and are not covered by insurance because of high variability in effectiveness (5). Clinicians who learn of a patient’s intent to purchase a dog could redirect them toward proven management strategies, such as continuous glucose monitors. Our conclusions are not generalizable to financially distressed patients who may not seek crowdfunding because of older age (people who use crowdfunding are generally younger [3]), poor internet access, or other reasons. Our use of content analysis limited our ability to consider textual context. We could not evaluate for fraud or consider patients’ reported versus actual financial needs. The expenses for which patients use crowdfunding include life-sustaining expenses, such as food and hospitalizations; unproven therapies, such as diabetic alert dogs; and less essential indirect costs, such as personal trainers. Future research should evaluate whether and how these expenses contribute to financial distress in the larger population of patients with diabetes, including those who do not use crowdfunding.
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    The influence of healthcare financing on cardiovascular disease prevention in people living with HIV.
    (BMC public health, 2020-11) Webel, Allison R; Schexnayder, Julie; Rentrope, C Robin; Bosworth, Hayden B; Hileman, Corrilynn O; Okeke, Nwora Lance; Vedanthan, Rajesh; Longenecker, Chris T

    Background

    People living with HIV are diagnosed with age-related chronic health conditions, including cardiovascular disease, at higher than expected rates. Medical management of these chronic health conditions frequently occur in HIV specialty clinics by providers trained in general internal medicine, family medicine, or infectious disease. In recent years, changes in the healthcare financing for people living with HIV in the U.S. has been dynamic due to changes in the Affordable Care Act. There is little evidence examining how healthcare financing characteristics shape primary and secondary cardiovascular disease prevention among people living with HIV. Our objective was to examine the perspectives of people living with HIV and their healthcare providers on how healthcare financing influences cardiovascular disease prevention.

    Methods

    As part of the EXTRA-CVD study, we conducted in-depth, semi-structured interviews with 51 people living with HIV and 34 multidisciplinary healthcare providers and at three U.S. HIV clinics in Ohio and North Carolina from October 2018 to March 2019. Thematic analysis using Template Analysis techniques was used to examine healthcare financing barriers and enablers of cardiovascular disease prevention in people living with HIV.

    Results

    Three themes emerged across sites and disciplines (1): healthcare payers substantially shape preventative cardiovascular care in HIV clinics (2); physician compensation tied to relative value units disincentivizes cardiovascular disease prevention efforts by HIV providers; and (3) grant-based services enable tailored cardiovascular disease prevention, but sustainability is limited by sponsor priorities.

    Conclusions

    With HIV now a chronic disease, there is a growing need for HIV-specific cardiovascular disease prevention; however, healthcare financing complicates effective delivery of this preventative care. It is important to understand the effects of evolving payer models on patient and healthcare provider behavior. Additional systematic investigation of these models will help HIV specialty clinics implement cardiovascular disease prevention within a dynamic reimbursement landscape.

    Trial registration

    Clinical Trial Registration Number: NCT03643705 .