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Cost-Sharing Mechanisms in Health Insurance Schemes: a Systematic Review

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Cost-Sharing Mechanisms in Health Insurance Schemes: a Systematic Review Cost-sharing mechanisms in health insurance schemes: A systematic review Submitted to The Alliance for Health Policy and Systems Research, WHO From Meng Qingyue, Jia Liying, Yuan Beibei Center for Health Management and Policy, Shandong University October, 2011 TABLE OF CONTENTS AbAbAb stract .............................................................................................................................................. 3 1 Background ..................................................................................................................................... 6 2 Objectives and definitions ............................................................................................................... 7 3 Criteria for inclusion of studies........................................................................................................ 7 4. Methods ........................................................................................................................................ 8 4.1 Searched databases and websites ........................................................................................... 8 4.2 Search strategy ........................................................................................................................ 8 4.3 Review method ...................................................................................................................... 10 5 Results .......................................................................................................................................... 11 5.1 Characters of the included studies ........................................................................................ 11 5.2 Content of cost sharing ......................................................................................................... 14 5.2.1 Distribution of cost-sharing methods in health insurance schemes ..................................... 14 5.2.2 Distribution of cost-sharing methods .................................................................................... 16 5.2.3 Target population covered by cost-sharing methods ............................................................ 16 5.2.4 Services covered by cost sharing methods ............................................................................ 18 5.3 Effect of cost sharing ............................................................................................................. 19 5.3.1 Effect of the introduction of cost sharing .............................................................................. 19 5.3.1.1 Full fee to cost sharing ................................................................................................... 19 5.3.1.2 Free to cost sharing ........................................................................................................ 20 5.3.1.3 Cost sharing to free ........................................................................................................ 27 5.3.2 Effect of the change of cost sharing methods ....................................................................... 28 5.3.3 Effect of different levels of cost sharing methods ................................................................. 43 6 Discussion ..................................................................................................................................... 52 6.1 Main results in this review .................................................................................................... 52 6.1.1 Improve Health utilization ..................................................................................................... 52 6.1.2 Control Moral hazard ............................................................................................................ 53 6.1.3 Financial risk changes ............................................................................................................ 55 6.2 Significance of this review..................................................................................................... 56 6.3 Limitation of this review ........................................................................................................ 57 Acknowledgement ........................................................................................................................... 58 Reference ......................................................................................................................................... 59 Annex1 Searching sources, strategies and results ............................................................................ 66 Annex2 screen process and results................................................................................................... 76 2 Cost-sharing mechanisms in health insurance schemes: A systematic review AbAbAb stract Background Cost sharing in health insurance schemes is a crucial method that would influence both health care utilization and financial burden of the insured population. Effects of cost sharing of health insurance schemes on demand for medical care have been examined in a number of studies. This review is to describe polices and interventions of cost sharing in health insurance schemes; and to describe how the authors have assessed effects of cost sharing methods in health insurance schemes where available. This review focuses on studies about methods of cost sharing applied in health insurance schemes. Health insurance schemes refer to any types of health insurance including public health insurance and private health insurance, country-level health insurance and local level health insurance. Cost sharing methods in this review included copayment, coinsurance and deductible. The mixed methods, including copayment plus coinsurance, copayment plus deductible, coinsurance plus deductible, copayment plus coinsurance and deductible were also included in our review. Studied populations were target population of cost sharing strategies applied in health insurance schemes. In this review, all types of study design (methods) except opinion paper, letter, news, comment, editorial, bibliography, methodological papers, and resource guides were included. Three types of outcome measures were used in this review, including use of health services or drugs, financial risk, and moral hazard. Methods We have searched the published and unpublished literatures about cost sharing methods in health insurance schemes. We have searched the Database of Abstracts of Reviews of Effectiveness (DARE) for related reviews. We searched the following electronic databases: Scopus, PubMed, EMBASE, ScienceDirect, Web of Science, WHOLIS, ELDIS, Global health library, 3ie database of impact evaluations, IBSS, Popline, EconLit, IDEAS, ProQuest, World Health Organization, China National Knowledge Infrastructure, Chinese Medicine Premier (Wanfang Data), OpenSIGLE, NTIS. Related articles also searched by the references of the included studies. We used a pilot stage to test and improve the data extraction form. Relevant information about health insurance schemes, contents of cost sharing methods, and the effects of cost sharing methods were extracted from included documents by two reviewers independently. We firstly described the distribution of all the included studies based on the information we gained via data extraction, which include study location, study time, and study design. Secondly we analyzed the contents of cost sharing policy applied in different countries, which include the health insurance schemes applying different cost sharing methods, the distribution of different cost sharing methods, the target population covered by the cost sharing policy, the health services or drugs used by target population during cost sharing policy. Thirdly we 3 synthesized the key information of cost sharing methods based on the theory framework. Major results A total of 8,057 articles were searched, and 6,904 were left for screening after checking duplications. After screening titles and abstracts, 219 were labelled for retrieval of the full text, of which we were able to obtain 176 full-text documents. Cost sharing methods were used in varied kind of health insurance schemes. In US, employed-sponsored or private health insurance, Medicaid and Medicare all even used copayment in their designation of insurance scheme. Majority of studies in Canada and Australia researched the cost sharing methods used in drug insurance. Studies in Taiwan, Israel, Japan, Belgium, Finland and Germany indicated that their national health insurance tried to introduce or change their copayments/coinsurance. Uganda and India had tested different cost sharing arrangements in their community based health insurance. The categories of cost-sharing methods used by different countries were diverse. Most frequently used method by different health insurance schemes were introduction of copayment and increase the level of copayment, and there were also lots of studies comparing the different copayment levels used by different insurance schemes. Coinsurance, deductible or ceiling and mixed method were less used. The influences of cost sharing methods on utilization of drugs and outpatient services were most frequently studied. The other kinds of health services which were analyzed included diagnostic services, dental services and surgical services, etc. The introduction of cost sharing means a new cost sharing method is implemented no matter it was from free to cost-sharing or full fee to cost-sharing.
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