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. Totally 74 studies included in this review were to describe a newly cost sharing policy implemented and evaluate its effectiveness. Cost sharing methods were widely used in public health insurance schemes such as National Health Insurance in Taiwan, China; Medicare and Medicaid in US; Germany statutory health insurance; Health insurance in Korea; Medicare in Australia; Public drug health insurance program in Canada, but the effects were different. In this review, 54 included studies described or evaluated the effects of cost sharing by comparing different levels of cost sharing methods applied in health insurance schemes. And most (52) of them were about private health insurance schemes. Discussion One of the purposes of cost sharing is to change the utilization of services or prescription drugs for the enrollee of public or private health insurance schemes. Compared with people in insurance scheme without cost sharing, the introduction of cost sharing decreased the utilization of most kinds of medical services. Different levels of cost sharing could bring different extent of changes in health services utilization.

4

Prescription cost sharing policy seems as a successful tool to control moral hazard both in private health insurance schemes and Medicare. In private health insurance, one of the purposes of cost sharing policy is to control moral hazard by decreasing over consumption of high price drugs and improve the use of generic drugs. The similar result was found in different levels of copayment policy. In public health insurance, the prescription copayment policy is also an effective instrument to control moral hazard. For health policy makers, there are rich materials which could be gained from this systematic review. In this study, we included all kinds of health insurance schemes which practiced cost sharing policy. And according to our analysis, they played different roles to control moral hazard and change financial risk. We synthesize the key information from the included studies based on three categories of cost sharing policy implementation: a new introduction of cost sharing, changes (decrease or increase) of cost sharing levels, different levels of cost sharing methods. These could be matched to different phrases of health policy making.

5

Cost-sharing mechanisms in health insurance schemes: A systematic review

1 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. The economic purpose of health insurance is to reduce financial risk of illness for the insured. Facing decreasing prices of health care paid by the insured, the insured have incentive to increase their health care utilization due to the price elasticity, even if some health services are not necessary (moral hazard). In health insurance schemes, cost sharing which can take various forms including deductible, co-insurance or co-payment, and ceiling implies higher out-of-pocket payment from the insured for health service. From demand side, the cost sharing mechanism could prevent users from utilization of health care; from the insurance designers’ side, the cost sharing could control the cost of health insurance scheme by correcting the problem of moral hazard. But too high level of cost sharing may make health insurance loose the function of financial protection. Hence the choice about health insurance involves a trade-off between the gains from risk reduction and losses from the incentive to purchase more health care when insured (moral hazard)(Manning and Marquis 1996). Many studies examined the existence of moral hazard by estimating the change of health care demand after change of cost sharing arrangements (Koc 2005). In Manning’s study (1996), an estimate of optimal co-insurance rate of 45% was derived using empirical data at which the marginal gains from increased pooling equals the marginal loss from increased moral hazard. However, due to the complexity of health insurance scheme, including the design of benefit package, premium level, and characteristics of the insured, optimal demand-side cost sharing level may be difficult to find. Effects of cost sharing of health insurance schemes on demand for medical care have been examined in a number of studies. The experimental studies from RAND are the most influential ones in which price elasticity of health services was examined by exploring the differences of health care utilization between participants in health insurances with different cost sharing levels(Newhouse, Manning et al. 1981; Manning, Newhouse et al. 1987). Similar studies could be also found in other countries, for example, in Korea (Kim, Ko et al. 2005). One relevant review was also found, in which evidences about effects of cost sharing on drug prescriptions(Gibson and R 2005) were collected and presented. This review was to determine whether patients responded to increased cost sharing by substituting less expensive alternatives for medications with higher levels of copayments or

6 coinsurance. And this review was not systematic and only focused on association between cost sharing and drug consumptions. Our review will be a systematic scoping review. Results from this review are expected to be helpful for improving health insurance schemes by developing reasonable costing sharing mechanism. In our review, we will include coinsurance, copayment, deductible, ceiling or mixed mechanism used by all types of health insurance schemes.

2 Objectives and definitions

The objectives of this review are: 1) To describe polices and interventions of cost sharing in health insurance schemes; and 2) To describe how the authors have assessed effects of cost sharing methods in health insurance schemes where available.

3 Criteria for inclusion of studies

This review focus 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. We also include some cost sharing programs such as drug cost sharing program which was implemented under some health insurance schemes. 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. Use of health services or drugs: Number or rate of health service utilization or prescription drugs. This outcome means the trend or changes of the target population consuming health services or drugs because of the implementation or change of cost sharing policy. Financial risk is another outcome measure, which means how the medical burden rose or decreased for the target population after cost sharing implemented or changed, or what is the differences in medical financial burdens between target populations with different levels of cost sharing.

7

Moral hazard means over consumption of health services or drugs. In this review we use control moral hazard as the indicator to evaluate whether the cost sharing realize this aim.

4. Methods

4.1 Searched databases and websites

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:
The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness
The Cochrane EPOC Specialized Register(and the database of studies awaiting assessment)
Cochrane library(CDSR: Cochrane database of systematic reviews; HTA: health technology Assessment Database; NHS Economic Evaluation Database ，NHS EED)
Scopus
PubMed
EMBASE
ScienceDirect
Web of Science
WHOLIS
ELDIS
Global health library
3ie database of impact evaluations
IBSS (International Bibliography in Social Science)
Popline (Population Information Online)
EconLit
IDEAS (Research Papers in Economics)
ProQuest Dissertation & Theses Database
World Health Organization – Publications
China National Knowledge Infrastructure (CHKD-CNKI)
Chinese Medicine Premier (Wanfang Data)

We searched the database which indexed the grey literatures such as:
OpenSIGLE (System for Information on Grey Literature in Europe)
NTIS (National Technical Information Service) We also searched relative articles based on the references of the included studies.

4.2 Search strategy Search strategies were designed by the topic experts, review group and search experts, after several times of discussion and search pilots in PubMed. The search strategy in PubMed is as follows. 8

#1: “cost sharing” [MH] #2: deductibles and coinsurance [MH] #3: “cost sharing”[TIAB] OR cost-sharing[TIAB] OR OR coinsurance [TIAB] OR co-insurance [TIAB] OR deductibles[TIAB] OR deductible[TIAB] OR copayment [TIAB] OR copayments[TIAB] OR co-payment[TIAB] OR co-payments[TIAB] OR copay[TIAB] OR copays[TIAB] OR co-pay[TIAB] OR co-pays[TIAB] OR ceiling[TIAB] OR ceilings[TIAB] OR “out-of-pocket payment”[TIAB] OR “out-of-pocket payments”[TIAB] OR “out-of-pocket expenditure”[TIAB] OR “out-of-pocket expenditures”[TIAB] OR “OOP”[TIAB] OR “out of pocket payment”[TIAB] OR “out of pocket payments”[TIAB] OR “out of pocket expenditure”[TIAB] OR “out of pocket expenditures”[TIAB] OR “user fee”[TIAB] #4: #1 OR #2 OR #3 #5: "Health Services/utilization"[MH] #6: ("Health Services"[MH] OR "Delivery of Health Care"[MH] OR “health care” [TIAB] OR “health service”[TIAB] OR “health services”[TIAB] OR “preventive service” [TIAB] OR “preventive services” [TIAB] OR “medical care” [TIAB] OR “medical service”[TIAB] OR “medical services”[TIAB] OR ambulatory[TIAB] OR “pathology service” [TIAB] OR “pathology services” [TIAB] OR “pharmaceutical service” [TIAB] OR “pharmaceutical services” [TIAB] OR “chronic service”[TIAB] OR “chronic services”[TIAB] OR “provider service” [TIAB] OR “provider services” [TIAB] OR “physician service” [TIAB] OR “physician services” [TIAB] OR “hospital care” [TIAB] OR drug[TIAB] OR drugs[TIAB] OR prescription [TIAB] OR prescriptions[TIAB] OR medication[TIAB] OR medications[TIAB] OR medicine[TIAB] OR medicines[TIAB] OR healthcare[TIAB]) AND ( use[TIAB] OR utilization[TIAB] OR utilisation[TIAB] OR access[TIAB] OR accessibility[TIAB]) #7: "physician visit"[TIAB] OR "physician visits"[TIAB] OR "outpatient visit"[TIAB] OR "outpatient visits"[TIAB] OR hospitalization[TIAB] OR hospitalized [TIAB] OR hospitalisation[TIAB] OR hospitalised [TIAB] OR "moral hazard"[TIAB] OR "adverse selection"[TIAB] OR "price elasticities"[TIAB] OR "price elasticity"[TIAB] OR overutilization[TIAB] OR overutilizations[TIAB] OR overutilisation[TIAB] OR overutilisations[TIAB] OR over-utilization[TIAB] OR over-utilizations[TIAB] OR over-utilisation[TIAB] OR over-utilisations[TIAB] OR "hospital admission"[TIAB] OR "hospital admissions"[TIAB] #8: “cost of illness”[MH] OR “financial risk”[TIAB] OR “financial risks”[TIAB] OR “financial burden”[TIAB] OR “financial burdens”[TIAB] OR ((cost[TIAB] OR costs[TIAB] OR burden[TIAB] OR burdens[TIAB] OR expense[TIAB] OR expenses[TIAB]) AND (illness[TIAB] OR illnesses[TIAB] OR sickness[TIAB] OR sicknesses[TIAB] OR disease[TIAB] OR diseases[TIAB])) OR “health expenditures”[MH] OR “health expenditure”[TIAB] OR “health expenditures”[TIAB] OR “household expenditure” [TIAB] OR “household expenditures” [TIAB] #9: #5 OR #6 OR #7 OR #8 #10: #4 AND #9 #11: letter[PT] OR news[PT] OR comment[PT] OR editorial[PT] OR bibliography[PT] OR resource guides[PT]

9

#12: #10 NOT #11 We made transferred strategies in other databases or websites according to the characters of them based on the PubMed strategy. The specific searching strategies are attached in annex 1 .

4.3 Review method

Screening We used a pilot stage to test the screen criteria, in which 20% of searched results were randomly selected and independently assessed by two of the authors, and then reviewers discussed to ensure the same screen approach was being used. In the screen process, each paper identified was screened by the reading titles and abstracts and then the full texts of all the literatures including titles and abstracts were searched. The retrieved full texts were screened and the final included items were identified. The process of screening was done and recorded in the Endnote. The screening process and result in this review was attached in Annex 2. Data extraction Data extraction was done by 3 authors independently. Initially, we also took 20% of the results from the screening process to pilot data extraction form, in which all the articles were double extracted making use of coding form designed in protocol, and then the differences in data extraction form and problems in coding form were identified and discussed by all reviewers and subject experts. After pilot, the coding form was adjusted and improved. Relevant information about health insurance schemes, contents of cost sharing methods, and the effects of cost sharing methods were extracted from included documents. Data analysis 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 synthesized the key information of cost sharing methods based on the theory framework as Figure 1. In this review, we analyzed the effect of cost sharing based on the process of health policy making: the introduction of cost sharing; different levels of cost sharing; changes of cost sharing. Three main outcomes were considered: improve health utilization, reduce financial risk, control moral hazard. We listed all the methods of cost sharing used in health insurance programs and how the authors have assessed its effectiveness on outcome indicators if it is available. We presented the outcomes of cost sharing by subgroups such as different types of targeting populations, different health insurance types and different kinds of health services. 10

Reduce financial risk

Access to health Lower cost sharing Full fee services or drugs Cost sharing

Free charge Over consumption of Higher cost sharing health services or drugs

Control moral hazard

Figure1 Conceptual framework for analysis

5 Results

A total of 8057 articles were searched, and 6904 were left for screening after checking duplications. Out of the 6905 articles screened, 123 articles were excluded as they were opinion papers, letters, news, commentary, editorial, or bibliography; 6063 articles were excluded as they were not the studies without descriptions on contents of cost sharing used by health insurance schemes; 141 studies excluded because they were theoretical, methodological studies or work plans, and cost sharing methods in articles have not been implemented; 137 articles excluded because there was no change on the cost sharing methods studied; and 222 studies were excluded as there was no outcomes about health care utilization or financial risks. In addition, 42 documents cannot be judged whether they need to be included or not because full texts of those documents were not retrieved. Finally 176 documents met the inclusion criteria and were used in this review. Annex2 demonstrates the screening process. 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. Of the 42 we did not obtain, 35 documents were published articles in Journals, and 2 documents were book or book chapters we could not access to. The remaining 5 articles were unpublished reports or thesis and their sources are not clear. 5.1 Characters of the included studies Study sites: Of 176 studies, most of them (114) researched the cost sharing methods used by health insurance in United States, and only about 20 studies are about cost sharing

11 methods used in Middle and Low Income Countries/districts, such as Uganda, India, Israel, Kyrgyzstan and Taiwan, China (Table 1). There is one study comparing cost sharing arrangements of health insurance in Germany and Switzerland.

Table 1: Study sites of included studies

Country Number Australia 4 Belgium 2 Burkina Faso 1 Canada 14 China 1 Colombia 1 England 1 Finland 1 France 1 Germany 8 Germany and Switzerland 1 India 1 Israel 1 Italy 1 Japan 4 Korea 1 Kyrgyzstan 1 Netherland 2 Rwanda 2 Switzerland 1 Taiwan, China 8 Uganda 2 United States 114 Vietnam 2 Zaire 1

Study time: We found that about 50% of included studies were done after Year 2000. In US, there are the studies evaluating effects of cost sharing methods since 1960s. And in US the relatively large number of studies in 1970s was due to RAND designing the Health Insurance Experiments at that time period.

Table 2: Study time of included studies

Country Before 1969 1970-1979 1980-1989 1990-1999 After 2000 Australia 1 3 Belgium 2 Burkina Faso 1 Canada 4 10 China 1 Colombia 1 England 1 Finland 1 France 1 Germany 1 7 Germany and 1 Switzerland

12

India 1 Israel 1 Italy 1 Japan 3 1 Korea 1 Kyrgyzstan 1 Netherland 2 Rwanda 2 Switzerland 1 Taiwan, China 4 4 Uganda 1 1 United States 2 28 6 18 60 Vietnam 2 Zaire 1

Study design: The largest number of studies was retrospective cohort studies, which usually made use of existing databases, found different cohorts with different designs of cost sharing methods, and then observed the differences in health utilization and financial risks between different cohorts. There were also lots of studies applying the design of before and after study to analyze the changes in health utilization and financial risks after change of cost sharing level. Most of controlled trials were studies using trial data from Health Insurance Experiments done by RAND.

Table 3: Study design of included studies

Country Controlled Cohort Time Controlled Before Cross Descriptive trial study series before and and sectional study study after study after study study Australia 1 3 Belgium 2 Burkina Faso 1 Canada 3 5 4 2 China 1 Colombia 1 England 1 Finland 1 France 1 Germany 3 2 3 Germany and 1 Switzerland India 1 Israel 1 Italy 1 Japan 1 2 1 Korea 1 Kyrgyzstan 1 Netherland 2 Rwanda 2 Switzerland 1 Taiwan, China 1 1 1 4 1 Uganda 2 United States 16 33 14 22 13 15 1 Vietnam 2

13

Zaire 1

5.2 Content of cost sharing

5.2.1 Distribution of cost-sharing methods in health insurance schemes The cost sharing method most frequently researched by existing studies is copayment. In US, employed-sponsored or private health insurance, Medicaid and Medicare all even used copayment in their designation of insurance scheme. For example, a kind of employed-sponsored health insurance (The Kaiser Permanent Medical Care Program) in Northern California US introduced copayment $25-$35 for emergency department services, and Selby’s study evaluated the effects of this copayment on the number of emergency visits(Selby, Fireman et al. 1996). Several studies evaluating cost sharing methods in US mentioned managed care originations or preferred provider organization, but didn’t explicitly described the name and nature of these insurance schemes. 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. We also found that two developing countries (Uganda and India) had tested different cost sharing arrangements in their community based health insurance. For example, the community based health insurance in Kabarole district of Uganda introduced copayment between 50 to 500 shillings (US$0.05-0.5) for one outpatient consultation, and the Kipp’s study found a decrease in overall outpatients’ visits(Kipp, Kamugisha et al. 2001).

Table 4: Distribution of cost-sharing methods in health insurance schemes

Cost sharing methods Country Health insurance Deductible Copayment Coinsurance Mixed or ceiling Australia Drug insurance (3) 3 Public health 1 insurance (1) Belgium Compulsory health 1 Copayment+coinsurance+ceiling(1) insurance (2) Burkina Community based 1 Faso health insurance (1) Canada Drug insurance (12) 3 1 Copayment+deductible(1) Copayment+deductible+ceiling(1) Copayment+coinsurance+deductible(2) Copayment+coinsurance(1) Coinsurance+deductible(1) Coinsurance+ceiling(2) Not clear (2) 1 Coinsurance+ceiling(1) China Community based 1 health insurance (1) Colombia Contributive 1 insurance, subsidized insurance and special 14

insurance pools(1) England National health 1 system (1) Finland National health 1 insurance (1) France Complementary 1 health insurance (1) Germany Compulsory health 5 2 Copayment+deductible(1) insurance (8) Germany Compulsory health 1 and insurance (1) Switerland India Community based 1 health insurance (1) Israel National health 1 insurance (1) Italy Drug health 1 insurance (1) Japan Employee health 1 3 insurance (4) Korea National health 1 insurance (1) Krygyzsta Not clear (1) 1 Netherland Private health 2 insurance (2) Rwanda Micro health 2 insurance (2) Switzerland Basic health Copayment+deductible(1) insurance(1) Taiwan,Chi National health 7 Copayment+ceiling(1) na insurance (8) Uganda Community based 1 health insurance (1) Not clear (1) 1 USA Medicaid(13) 12 Copayment+ceiling(1) Medicare(20) 14 1 2 Copayment+coinsurance(1) Copayment+coinsurance+ceiling(1) Copayment +deductible(1) Employee or private 23 4 Copayment+coinsurance(6) health insurance (37) Copayment+coinsurance+deductible(1) Copayment+deductible(2) Coinsurance+deductible(1) Managed care 9 Coinsurance+deductible(1) organizations (10) Preferred provider 2 1 Coinsurance+deductible(1) organization (4) Other kinds of health 5 1 Copayment+coinsurance+deductible(1) insurance (7) Not clear (23) 10 7 Copayment+coinsurance+deductible(1) Copayment +deductible(1) Copayment+coinsurance (3) Coinsurance+deductible(1) Vietnam Social health 2 insurance (2) Zaire Community based 1 health insurance (1) Note: the number in bracket means the number of the included studies 15

5.2.2 Distribution of cost-sharing methods As Table 5 shows, 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. Few studies in Canada and US researched the effects of deductible or ceiling on the health services utilization. For example, to decrease nonessential outpatient visits and encourage a referral system, national health insurance in Taiwan increased the outpatient copayments in different kinds of health institutions except physician clinics(Chen, Schafheutle et al. 2009). Stein’s study investigated the effects of cost sharing on health utilization by comparing the 41 different health benefit plans with different copayment copayments in Columbia district of US(Stein and Zhang 2003).

Table 5: Distribution of cost-sharing methods used by country levels

Cost-sharing Introduction Change Compare methods Free to To free Full fee to Decrease Increase Free with cost Different cost cost sharing sharing levels sharing Copayment Canada(4) France(1) Rwanda(2) Finland(1) Australia(3) Germany and Canada(3) Israel(1) Uganda(1) Vietnam(2) US(3) Canada(1) Switzerland(1) Japan(1) Germany(4) US(1) Zaire(1) England(1) India(1) US(30) Kyrgyzstan(1) Germany(1) US(9) Taiwan Italy(1) China(6) Korea(1) Uganda(1) Taiwan US(17) China(2) US(20)

Coinsurance US(3) China(1) Belgium(1) US(2) Japan(1) Canada(1) US(5) Japan(2) Deductible Canada(2) US(1) Germany(1) Australia(1) or ceiling Germany(1) US(1) Netherland(2) US(5) Mixed Canada(4) Burkina US(1) Belgium(1) US(5) Canada(1) Switzerland(1) Faso(1) Canada(1) Colombia(1) US(2) US(4) Germany(1) US(11)

5.2.3 Target population covered by cost-sharing methods In Table 6, we grouped studies based on the populations influenced by the cost sharing methods. The cost sharing methods used by health insurance were not applied to only one kind of populations, but the academic studies usually only focused on the effects of cost sharing on one specific kind of populations. Employee, the poor and population with chronic disease were population most frequently researched by

16

studies evaluating cost sharing methods in US. The studies in the countries/districts with national or compulsory health insurance, like Finland, Taiwan, Israel and Germany, were less likely to examine the influences of cost sharing change on a specific kind of populations. Roblin’s study evaluated the impacts of copayments’ increase used by different US’s managed care organizations on adults with type 2 diabetes(Roblin, Platt et al. 2005). A study in Taiwan evaluated the introduction of copayments on drug prescription, and this copayment policy was applied to 98% of the population in Taiwan(Deborah A. Taira 2006).

Table 6: Target population covered by cost-sharing methods

Target Population Copayment Coinsurance Deductible or ceiling Mixed The poor France(1) US(2) US(11) Chronic disease Germany(1) Japan(1) US(4) US(12) The elderly Canada(2) US(1) Australia(1) Canada(7) Taiwan(3) Canada(1) US(4) US(9) US(1) Children US(4) US(1) US(2) Employee Japan(1) Belgium(1) US(3) US(5) US(15) Japan(1) Adults Korea(1) US(1) US(5) Non-aged US(3) US(1) US(1) General population Australia(3) Japan(1) Germany(2) Belgium(1) Canada(2) US(1) Netherland(2) Burkina England(1) Faso(1) Finland(1) Colombia(1) Germany(4) Germany(1) Germany and Switzerland(1) Switzerland( Israel(1) 1) Italy(1) Taiwan Rwanda(2) China(1) Taiwan China(4) Uganda(2) US(1) Vietnam(2) Zaire(1) Other kinds India(1) China(1) Canada(2) US(3) Not clear Kyrgyzstan(1) US(3) US(2) US(4) US(15)

17

5.2.4 Services covered by cost sharing methods Table 7 shows how many different kinds health services were influenced by cost sharing methods. The influences of cost sharing methods on utilization of drugs and outpatient services were most frequently studied. In not a few studies, the cost sharing methods were not applied to a specific kind of health services, but a comprehensive range of health services. The other kinds of health services which were not listed on the table included diagnostic services, dental services and surgical services, etc. Studies of Sedjo, Gibson and Esposito all researched how private health insurance in US made use of copayment to influence the statin prescription(Sedjo and Cox 2008) (Gibson, Mark et al. 2006) (Esposito 2003). Israel’ national health insurance introduced different level copayments for outpatients in different levels of health institutions in 1998, and Vardy observed the decreases in outpatients visits in each level of health institutions by a simply before and after study design(Vardy, Freud et al. 2006).

Table 7: Services covered by cost sharing methods

Deductible or Services Copayment Coinsurance Mixed ceiling Outpatient visits Canada(1) Belgium(1) Germany(1) Belgium(1) Israel(1) Japan(1) Germany(1) Germany(4) US(1) Switzerland(1) Germany and Switzerland(1) US(5) Korea(1) Rwanda(1) Taiwan China(2) Uganda(2) US(8) Inpatient India(1) Japan(1) US(2) US(2) Kyrgyzstan(1) US(2) Zaire(1) Emergency US(7) US(2) Canada(1) US(1) Drugs Australia(3) Canada(1) Canada(9) Canada(4) US(1) US(6) England(1) Finland(1) Germany(1) Italy(1) Taiwan China(3) US(43) Mental services US(5) US(1) US(1) Prevention US(3) US(2) Comprehensive France(1) China(1) Australia(1) Burkina Faso range of health Rwanda(1) Japan(1) Netherland(2) (1) services Taiwan China(2) US(5) US(1) Colombia(1) US(11) Taiwan Vietnam(2) China(1) US(5) Other kinds US(5) US(1) US(2) US(4) Not clear Japan(1) Germany(1) US(1) US(1) 18

5.3 Effect of cost sharing

According to the theory framework, we classify the included studies into three types, and synthesize them: effect of the introduction of cost sharing, effect of changes of cost sharing level and effect of different levels of cost sharing. 5.3.1 Effect of the introduction of cost sharing 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. Free to cost-sharing means health insurance schemes originally covered all the costs of health services or drugs for their target population, and then the population had to pay some medical costs for their consumption of health services or drugs after the implementation of cost sharing. Full fee to cost-sharing means the target populations originally had to pay all the cost of health services or drugs out of pocket before introducing the cost sharing scheme, which always happened when a health insurance scheme was implemented or some policy changes happened in a health insurance scheme. Totally 74 studies included in this review were to describe a newly cost sharing policy implemented and evaluate its effectiveness. 5.3.1.1 Full fee to cost sharing New Cooperate Medical Scheme (NCMS) in China New Cooperate Medical Scheme(NCMS) in rural China, as a kind of community based health insurance and a cost sharing scheme was implemented in 2005, in which the beneficiaries needed to pay 20% of hospital outpatient cost and 20-80% of inpatient, up to a ceiling of 10 000 Yuan per person per year. This cost sharing policy reduced financial risk of the beneficiaries: catastrophic out of pocket payments of the intervention group decreased from 8.98% to 8.25% after reimbursements, and catastrophic severity for households remaining in catastrophe after reimbursement dropped by 18.7% to an average of 6.34 times the household’s CTP(Sun, Sukhan et al. 2009). Bwamanda hospital insurance scheme, Zaire Bwamanda hospital insurance scheme is a voluntary, community-based health insurance, with a 20% copayment for hospital admission. A retrospective study conducted by Criel (Criel, Van der Stuyft et al. 1999) showed that hospital admission rate of the insured (49%) is nearly 3 times higher than the non-insured (17%), 10 timers higher for surgery, and 7 times for maternity. A formal social insurance scheme in Vietnam Official co-payment by the insured patients is 20% in the social health insurance in Vietnam. This cost sharing policy reduced the financial risk of the insured by 16%

19 and 18%, and this reduction in expenditure is more pronounced for individuals with lower incomes. For the individuals with the mean income, the effect of health insurance was to reduce health expenditures between 28 and 35% (Jowett, Contoyannis et al. 2003; Ardeshir, Sisira et al. 2006). Micro-health insurance (MHI) schemes in Rwanda Insured patients pay a RWF 100 (US$ 0.30) co-payment per episode of illness in health centres; and user fees still existed for those not covered by MHI. User-fee paying individuals reported significantly lower visit rates than the insured. This means financial risk of the insured was reduced(Pia and Kara 2006). Those with MHI coverage were significantly more likely to use health services than the non-insured when getting illness(Saksena, Antunes et al. 2011). 5.3.1.2 Free to cost sharing In the included studies, some health insurance schemes which included NHI, Medicare, Medicaid, Group Health, managed care, private health insurance, drug insurance, High deductible health plans introduced a cost sharing method. Most of the authors analyzed the effect of these cost sharing methods by comparing them with pre-policy situations or with other health insurance schemes which didn’t introduced cost sharing methods. National health insurance (NHI) in Taiwan, China Shuen-Zen Liu (Liu and Romeis 2003; Liu and Romeis 2004) assessed the effects of 1999 NHI’s outpatient prescription drug cost-sharing program for the elderly in Taiwan, China. People with low incomes (earning less than 60% of average personal consumption level in the community), emergency visits, major illness (eg, renal failure), preventive care, and people with extended prescriptions for chronic diseases were exempted from the cost-sharing program. The researchers found that after cost sharing being introduced: For the use of prescription , compared with the non cost-sharing group, the increase rates of total number of prescriptions, number of patients in cost sharing group were 16.87% and 9% smaller; For the financial risk, average prescription cost increase rate was lower (22.05% to 7.78%) in the cost sharing group; for the elderly with chronic diseases, there was a significant increase in drug costs (from 88.06% to 91.46%) above the upper bound of the cost-sharing schedule which was induced by physicians who seemed to prescribe more expensive drugs and extend prescription duration, especially when drug costs exceed the upper bound of the cost-sharing schedule. For the moral hazard , the elderly with non-chronic diseases in the cost-sharing group decreased (1.79%) the use of essential drugs and increased (10.98%) the use of non-essential drugs which means there were some moral hazard happened followed the cost sharing policy In 2005, National Health Insurance implemented a cost sharing policy to control moral hazard, NT$ 50–210 for outpatient, 5–30% for inpatient. The studies (Chen, Liu et al. 2007) showed that neonatal care and free well-baby care increased by less than 1% (from 89.76 and 53.98% in the pre-NHI period to 90.64 and 54.54% in the 20 post-NHI period); utilization of neonatal care had strongly negative significant coefficients for the likelihood of being admitted to the hospital. And this means the cost sharing policy indeed have some effect to control moral hazard. Health insurance in Korea Korea has achieved universal coverage of health insurance since 1989 but the Korean government has raised coinsurance rates several times to control its health insurance expenditures(Kim, Ko et al. 2005) concluded that the cost sharing policy in Korea did not efficiently work. Patient cost sharing in Korea resulted in inequitable medical service utilization and also it did not decrease moral hazard in the sense that the higher cost-sharing sector is less sensitive to cost sharing. Germany statutory health insurance Two cost sharing policies were implemented in Germany, and some authors evaluated the effect of them and got different outcomes. Techniker Krankenkasse (TK) launched its“deductibles ”pilot scheme in January 2003. The fixed deductible of €20 per visit caused a reduction of 23.5% in consultations with general practitioners and 42% in consultations with specialists. TK’s total costs for hospital treatment, inpatient prophylactic measures and pharmaceuticals was reduced by €68.4 per participant in the case of the deductible(Claudia and Christian 2006). The German health care reform of 2004 imposed a charge of €10 for the first visit to a doctor in each quarter of the year (the so called “Praxisgebühr”). In Augurzky’s study, the effect was that the cost sharing policy increased use of visit a doctor by 0.003(Augurzky, Bauer et al. 2006). But in Farbmacher and Jochen Schmitt’s study(Farbmacher 2009; Schmitt, Kirch et al. 2009), the outcome was negative. There is a small but significant decrease in the probability of visiting a physician (-0.0419) for the general population in Farbmacher’s study. Jochen Schmitt studied the effects of the policy for the patients with atopic eczema (AE), and the result showed that the target population decreased treated by dermatologists from 52.8 % to 42.3%; the adverse effect was that systemic steroids for AE significantly increased from 5.9 % to 10.3 % by males, from 5.7 % to 8.2 % by females. In Schmitz’s study, the marginal effect of deductible was about zero. Conditional on the health status and risk preferences, holding private insurance with a deductible did not seem to lower the probability of visiting a doctor. Mandatory basic health insurance in Switzerland The Swiss health system reform in 1996 introduced a choice of deductibles for health services in the mandatory basic health insurance. There were variable health insurance deductibles for physician visits: minimal deductible was 150SFr; higher deductibles were 300, 600, 1200, or 1500 SFr. And there was also a copayment of 10% for costs exceeding the deductibles. The study found that primary physician visits decreased for those having higher deductibles than the minimal level for both man and

21 woman(Martin 2001). Medicare in Australia Gool (2006) described the introduction of the ceiling for Medicare beneficiaries in Australia, and the ceiling was about $500 (up from $300) for low and middle income households and $1,000 (up from $700) for others, after which the out of pocket payment of the beneficiaries showed a small and significant fall in 2005. Rand Health Insurance Experiment (HIE) A randomized trial was conducted in 6 sites of USA from 1972 to 1984, it implemented different levels of cost sharing methods for a wide variety of services. 13 included studies used the data from this experiment to analyze the change in the use of different services or medications for different population, and 6 studies analyzed the financial risk outcomes among different cost sharing groups. For health utilization Totally 10 kinds of services or medications utilization were analyzed by the authors, which included medical services, hospitalization, pathology services, outpatient visits, psychotherapy services, dental services, diagnostic/preventive treatment or restorative treatment. Compared with free plan group, most of the health services utilization changes were negative except that hospitalization of population aged ≤15 was 3-5% higher. Different levels of cost sharing also resulted in different extent of changes, for example, prescription size for general populations with 25% coinsurance, 50% coinsurance, PFD, IDP less 2.77, 3.25, 4.80 and 1.78 than free plan respectively. (Table 8) For financial risk Generally, the introduction of cost sharing policy lowered the spending on most of health care services. Anderson found that compared with free care, cost sharing led to a statistically significant 30% decreased in medical charges and a statistically significant 45% decrease in pathology charges(Anderson, Brook et al. 1991). Some authors compared with 95% cost sharing level plan, the per capita expenses in the free plan were 45 percent higher, drug expenditures per person in the free care plan were about 60% higher, the dental expenses were 46% higher(Manning, Bailit et al. 1985; Foxman, Valdez et al. 1987; Manning, Newhouse et al. 1987). For moral hazard Manning (1987) showed that for the poor adults who were with high blood pressure at the beginning of the experiment, there was a clinically significant reduction in blood pressure for those in the free plan compared to those in the plans with cost sharing, and the magnitude of this reduction would lower mortality about 10 percent each year among this group, about 6 percent of the whole population.

Table 8: Utilization changes on cost sharing in Rand health insurance

Service or medication Population Use Changes compare with free plan Total Medical services General population 50% less 22

(Newhouse 1984) (Keeler 1992) ≤15 aged 26% less (Anderson, Brook et al. 1991 ) Hospitalization or inpatient service ≤15 aged 3-5% higher (13% to 3/5%) (Anderson, Brook et al. 1991) General population 80% ； 2/3 because of ED (Keeler and Rolph visits decrease 1983) (O'Grady 1985) Pathology services ≤15 aged 43% less (Anderson, Brook et al. 1991) Outpatient General General population 69% visits (Keeler and Rolph 1983) ED visits General population 66% less(95% coinsurance) (Manning, Newhouse et al. 1987) Antibiotics General population 80% less; 1/3(95% (Foxman, Valdez et al. coinsurance) 1987) Prescription number General population -2.77(25%); -3.25(50%); (Leibowitz, Manning -4.80(PFD); -1.78(IDP) et al. 1985) Psychotherapy services Non aged people 50% less (95% (Manning, Wells et al. coinsurance) 198 6) Dental services General Non aged people 34% less (Manning, Bailit et al. 1985) Prosthodontics services General population 62% smaller(95% (Manning, Bailit et al. coinsurance) 1985) Endodontics General population 1/2 smaller(95% &periodontics (Manning, Bailit et al. coinsurance) 1985 ) Diagnostic/preventive treatment or of any General population 1/3 lower(95% restorative treatment (Manning, Bailit et al. coinsurance) 1985) *means included studies number Medicare is a kind of social insurance program administered by the United States government, providing health insurance coverage to people who are aged 65 and over, and those who are under 65 but are permanently physically disabled or have a congenital physical disability, or those who meet other special criteria. Two studies (Hsu, Price et al. 2006; Trivedi, Rakowski et al. 2008) described the changes in utilization of mammography screen and ED visits for the target population caused by the implementation of copayment policy. These studies found that a $10 copayment lowered screening rates and biennial screening rates by 8.3% and 9.0% respectively, and a $20-50 copayment policy reduced ED visits by 4% compared with those without cost sharing .(Table 9) 23

Table 9: Utilization changes on cost sharing in Medicare

Service or Population Cost sharing Use Changes after cost sharing medication method policy Mammography Old women $10 copayment or 8.3% points lower Biennial screen aged 65-69 10% coinsurance screening rates; 9.0% points (Trivedi, Rakowski lower Screening rates et al. 2008) ED visits General $20–50 copayments Decreased 4% (95%CI: 3–6%) (Hsu, Price et al. population 2006)

Medicaid is a United States health program for certain people and families with low incomes. For health utilization and moral hazard A $1 outpatient copayment and 50 ￠ prescription copayment decreased the use of outpatient visits and consumption of drugs for the target population. A $1copayment for each of the two outpatient visits in a month caused the declined use, and the price elastic was -0.058(Jay, Jospeh et al. 1978). The study found that the greatest decline happened for the population with chronic diseases(Hopkins, Roemer et al. 1975), but this copayment kept the impoverished people getting the service, for example, overall 12% of AFDC (Aid to families of dependent children), the 15% of blind and disabled, the 20% of chronic diseases in the family said that the prescriptions copayment had kept them getting prescribed drugs; 50 ￠￠￠ for each of the first two prescriptions in a month decreased prescription utilization rate by 0.03(Nelson, Jr et al. 1984), and it also kept the impoverished people getting the drugs.(Table 10) We also included two articles about state-level Medicaid program in Oregan (Oregan health plan)(Lowe, McConnell et al. 2006; Lowe 2010) which applied a copayment policy for a variety of services: $2-$20 copayment for outpatient services (physician, vaccine or preventative services, lab and radiology), $2-$15 for prescription drugs, $50 for emergency services, $250 for inpatient services. Compare with non-cost sharing group, the utilization of all covered services reduced (-2.7%, p<0.001); the pharmacy utilization decreased (-2.2%, p<0.001); the utilization of all other medical services decreased (-4.7%, p<0.001); inpatients increased (+27.3%, p<0.001); hospital outpatient services increased (+13.5%, p<0.001); utilization of ambulatory professional (-7.7%, p<0.001) and emergency department (-7.9%, p=0.03) decreased for the general enrolled and 10% (41% to 31%) by patients with behavioral health. Financial risk The average expenditure of Medical eligible person per quarter increased by 3% and overall program cost increased 3-8%(Jay, Jospeh et al. 1978). Average monthly expenditure in SC was lower (48c) than no payment group, and the study(Nelson, Jr et al. 1984) concluded that a small (50) copayment for prescription service was a successful mechanism to control the cost. 24

Table10: Utilization changes on cost sharing in Medicaid

Service or population Cost sharing Use Changes after Changes of medication method cost sharing Financial risk the poor -0.058 for one a 3-8% increase in dollar; 0.024 days overall program for inpatient by one cost ；3% increase for dollar per visit average expenditure (Jay, Jospeh et al. 1978) general Declined - $1 for each of (Hopkins, Roemer Outpatient the first' two et al. 1975 ) visit office visits in a with chronic the greatest - month diseases declined (Hopkins, Roemer et al. 1975) AFDC, blind and kept them getting - disabled, chronic of care diseases (Hopkins, Roemer et al. 1975) AFDC, blind and kept them getting - disabled, chronic prescribed drugs diseases (Hopkins, Roemer et al. 1975 ) General -0.03 prescription - utilization rate (Nelson, Jr et al. 50 ￠ for each 1984) Description of the first two 0.19 less than no average monthly drug prescriptions in payment group expenditure in SC a month (Nelson, Jr et al. was lower(48c) than 1984 ) no payment group Decreased four of - therapeutic drug categories (Reeder and Nelson 1985) Public drug health insurance program , we found 6 articles described a mandatory drug insurance program which was implemented in British Columbia and Quebec, Canada. In different states, drug cost sharing methods were different: coinsurance and ceiling in Quebec; copayment, coinsurance, deductible and ceiling in British Columbia. The target population in both drug plans were the elderly, and changes in health services utilization were different for different kinds of populations because different characters of their health status or income level. For example, in Quebec drug plan, the welfare recipients’ utilization were more sensitive than the general elderly, but in British Columbia Pharmacare, for the elderly with rheumatoid arthritis (RA), the differences in prescription filled and physician visits were very small between the general and the poor. (Table 11) Financial risk change : Only 3 articles mentioned the changes of out of pocket

25 expenditures of target population. In British Columbia Pharmacare, the elderly’s financial risk changed a lot after cost sharing policy, for example, for the elderly with rheumatoid arthritis (RA), their out-of-pocket payments increased from C$119.5 to C$229.8(Li, Guh et al. 2007). After reference pricing (RP) was implemented in 1995, the program expenditures declined by $22.7 million. Most savings accrued from the substitution of low cost NSAIDs for more costly alternatives. About 20% of savings represented expenditures by seniors who elected to pay for partially-reimbursed drugs. But the effects of RP on patient health and associated health care costs remained to be investigated(Paul, John et al. 2004).

Table11: utilization changes on drug cost sharing programs

Cost sharing method Service or population Use Changes after Changes of medication cost sharing Financial risk General welfare reduced 15.94% - Prescription recipients overall number of drugs drugs used per day for elderly reduced 9.14% - people overall number of drugs used per day essential welfare 14.42% decreased - drugs recipients for elderly 9.12% decreased - people less essential welfare 22.39% decreased - Quebec drug plan: drugs recipients 25% coinsurance and for elderly 15.14% decreased - annual maximum $200 people in Quebec serious welfare a net increase of 12.9 - (Tamblyn, Laprise et al. adverse recipients [95% CI, 10.2-15.5] 2001) events (14.7 to 27.6) for elderly a net increase of 6.8 - people [95% CI, 5.6-8.0] (5.8 to 12.6) Emergency welfare increased by 54.2 - department recipients (95% CI, 33.5- 74.8) visit rates (69.6 to123.8) for elderly increased by 14.2 - people (95% CI, 8.5-19.9) per 10000 person-months (32.9 to 47.1 ) British Columbia inhaled patients over decreases 6% for β2 Median Pharmacare: medications 65 years of agonists; decreases monthly $10(for poor)/$25 per age who 13% each for steroids out-of-pocket prescription, a 25% chronically and anticholinergics spending rose coinsurance plus an C$8 (6 to 14) income-based deductible after (0% to 2%), an copayment, out-of-pocket ceiling C$13(14 to equal to 1.25%, 2%, or 27) after IBD 3% of income, or $50 individuals decrease 37% of - per 3 months, or annual receiving inhaled maximum out-of-pocket social corticosteroids use; payments of assistance decrease of 9% and 26

CAN$200(for poor)/ 10% for neuroleptics CAN$ 275 and anticonvulsant (Schneeweiss, Patrick et statin patients over Reduced 5.3% - al. 2007) 65 years of (55.8% to 50.5%) (Dormuth, Neumann et age who adherence to new al. 2009) chronically statin therapy (Blais, Couture et al. prescription The elderly decrease from 22.4 to Out-of-pocket 2003) filled and with 21.4 No. of payments (Li, Guh et al. 2007) physician rheumatoid prescription filled; increase from visits arthritis increase from 20.1 to 119.5 to 229.8 (RA) 20.5 physician visits The poor decrease from 23.5 to Out-of-pocket elderly with 22.5 No. of payments rheumatoid prescription filled; increase from arthritis increase from 19.5 to C$119.1 to (RA) 19.7 physician visits C$154.5 Other private health insurance High-Deductible Health Plans(HDHPs) decreased the use of outpatient and inpatient services for the enrollees, for example, deductible ranging from US$1,700 to US$6,000 was significantly associated with -0.49 level of primary care Physician use, 0.65 level of prescription drug utilization higher, -0.94 level of emergency room use, 0.44 level of specialty visits(Waters, Chang et al. 2011); annual deductibles ranging from $500 to $2000 for individuals and $1000 to $4000 for families were associated with a 10% relative decline in total emergency department visits, a 25% decrease in repeat visits ，a 27% relative decline in population hospitalization rates by the HDHP group, a 25% relative decline in the proportion admitted to the hospital and a 21% less in the length of stay in hospital compared with controls(Wharam, Landon et al. 2007).

For financial risk The average yearly out-of-pocket emergency department payment by HDHP members increased from $8 in the baseline year to $49 in the follow-up period compared with $9 for control members in both periods. This absolute increase of $41 was a 491% relative increase for HDHP members after adjustment (95% CI, 441%-547%; P.001)(Wharam, Landon et al. 2007). For moral hazard Saito (2010) analyzed the moral hazard rate of different levels of copayment (<$5; $5; $5-$15; $15; >$15) for patients with type 2 diabetes, and found that each $5 increase in copayment was associated with decreased rates of switching to a relatively more expensive drug (hazard ratio [HR] = 0.49, 95% confidence interval [CI] = 0.43, 0.56) and an increased rate of switching to drugs of equal or lower cost (HR = 1.04, 95% CI = 1.03, 1.05). Compared with the lowest copayment level (<$5) for the initial antidiabetic medication, higher copayment levels were associated with increased rates of drug switching, with an almost 2-fold increased rate for copayments of more than $15 (HR = 1.95, 95% confidence interval [CI] = 1.50, 2.53). 5.3.1.3 Cost sharing to free We also found some articles evaluating the effect of elimination of cost sharing in health insurance schemes which were called “cost sharing to free” in this review.

27

Cost sharing to free means the population needn’t pay any of the costs of the medical services after the elimination of cost sharing. Karter studied the effect of elimination cost sharing of test strips for self-monitoring of blood glucose (SMBG), which was implemented in 2000 to eliminate a financial barrier to SMBG because of the expensive test strips. But the utilization of test strips was not significantly increased in SMBG relative to the controlled(Andrew J. Karter 2007). Grignon (2008) assessed the impact of free complementary health insurance plan which acted in 2000, France, which was aimed to help the non-elderly poor (the poorest 10% of French) to access health care, and required no out-of-pocket payments by beneficiaries at the point of use and all physicians, dentists, and opticians must accept patients covered by the plan. The before-after analysis showed that enrolling in the free plan had a positive (+3.2% points) and almost significant effect on the probability of using any health care; a small negative and non- significant impact on utilization of GP services; a significant and large (+15.1% points) increase in the probability of using specialist care; a large positive, but again not significant impact on prescription drugs use(Grignon, Perronnin et al. 2008). Burnham (2004) assessed the effects of ending cost sharing on use of outpatient services. The intention of 2001 abolition of copayment US ＄0.25-0.45 policy was to improve access to health services for the poor (as 46% of Uganda’s population earned less than US$1 per day and 60% of households had a monthly income under US$50). The study showed the positive outcomes after ending cost sharing: the mean monthly number of new visits increased by 17928 (53.5%), but among children aged <5years the increase was 3611 (27.3%)(Burnham, Pariyo et al. 2004). 5.3.2 Effect of the change of cost sharing methods Health policy makers will modify cost sharing policies when they have to face the political or economic issues. The changes of cost sharing policies means the types of cost sharing methods will be changed such as from copayment to coinsurance, from copayment to deductible and so on; the levels of cost sharing methods will be changed such as decrease or increase copayment or coinsurance rate. In this review, about 48 articles described or appraised the main outcomes. National Health Insurance (NHI): Chen (2009) and Huang (2006) described how the changes of cost sharing policy affected targeted population’s use of outpatient and inpatient services in Taiwan, China . For general population, copayment level increased by 71% would decrease number of outpatient visits in medical centers by 13.1%; for the elderly, copayment increased by 3.55% followed by a 17% decreased hospital visits which accompanied with 11% increased total medical cost(Huang and Tung 2006; Chen, Schafheutle et al. 2009). In Finland , lower copayment by €50 in Basic Refund category and €4.20 in Special Refund category increased consumption of two drugs: dorzolamide by 109%, latanoprost by 21%(Martikainen, Hakkinen et al. 2007). Bernie studied increased 28 copayment prescription drugs from 1969 to 1986 in NHS England, and got the 1969-1986 price elasticity was -0.33 and exempt prescriptions was +0.17(O'Brien 1989).

Table 12: Utilization and financial changes on NHI cost sharing policy

Health population Cost sharing Change of health Change of services or method utilization financial risk drugs Outpatient General Medical centers: outpatient visits - visit population in NT$210 to significantly Taiwan NT$360 decreased by 13.1% (Chen, (NT$150; Schafheutle et al. 71%)* 2009) Physician The number of visits - clinics: NT$50 to physician clinics decreased 10.7% Inpatient All patients aged increase from The hospital visit The total medical services 65 and above in $5.12 to $6.00 frequency had a care costs Taiwan ($0.18; 3.55%) decrease of 0.17. increased from (Huang and Tung US$35.57 to 2006) US$39.55 ($3.98; 11%) Drugs General the Basic consumption of - population in Refund dorzolamide was Finland category: ~€50 109% higher, (Martikainen, per 3 months; latanoprost was 21% Hakkinen et al. the Special higher 2007) Refund category: fixed €4.20 per purchase

Medicaid For the poor patient, the increased description and outpatient copayment decreased the utilization and cost to the clinic, but did not significantly influence patients’ out of pocket costs(Lurk, DeJong et al. 2004).

Table 13: Utilization and financial changes on Medicaid cost sharing policy

Health population Cost sharing method Change of Change of services or health financial risk drugs utilization prescription Patients Copayment significant - drug applied for generic from $5 to decreases in Medicaid $7.50 ($2.5;50%) ; prescription drug brand from $10 to utilization and $15 ($5;50%) costs outpatient Patients per outpatient visit - a $26.07 decrease visit applied for copayment from $9 to in prescription Medicaid $14 ($5;56%) drug cost to the clinic per visit per month

Medicare Increased cost sharing in Medicare plans reduced the use of outpatient care

29 and increased inpatient care utilization among elderly enrollees or the generally insured.

In Trivedi’s (2010) study, for ambulatory care 95% increased copayment for general insured reduced the ambulatory care use by 6% in case plans and 26% in control plans, but hospital admissions rate increased 9% in case plans and 2% in control group. And case plans saved a total of $7150 from increased ambulatory copayments in return for an additional $24,000 in inpatient care expenditures in the year following the increase(Trivedi, Moloo et al. 2010). For mental health services, a study found that 46% increased copayment didn’t affect the use of mental services for the elderly(Ndumele and Trivedi 2011). For financial risk In a Medigap supplemental insurance(Zuckerman, Shang et al. 2010)，drug description copayment increasing deductible by 100% ($500 to $1000) was followed by a 6% increase in out-of-pocket spending from $587 to $621; a 25% increase in ceiling was followed by a 6% increase in out-of-pocket spending; a 10% increase in coinsurance from 10% to 20% was followed by a 4% increase in out-of-pocket spending.

Table 14: Utilization and financial changes on Medicare cost sharing policy

Health population Cost sharing method Change of health Changes of services or change utilization financial risk drugs Ambulatory General primary care from Increased 6%(702 to - visits population $7.38 to $14.38 ($7; 720.5 in case plans (Trivedi, 95%) in case plans; and 26%(753.4 to Moloo et al. $8.33 in control plans; 798.9) in control 2010) specialty care from plans $12.66 to $12.05 (per 100 enrollees) ($0.61 ；5%) in case plans; $11.38 in control plans Outpatient Elderly primary care 19.8 fewer per 100 - visits (Trivedi, copayment was $7.38 enrollees (95% Moloo et al. and by an average of confidence interval 2010) 95% increase [CI], 16.6–23.1) Hospital General primary care from Increase 9% (25.3 - admissions population $7.38 to $14.38 ($7, to 27.6) in case (Trivedi, 95%) in case plans; plans and 2%(25.8 Moloo et al. $8.33 in control plans to 26.1) in control 2010) specialty care from group $12.66 to (per 100 enrollees) $12.05 ($0.61 ；5%) in case plans; $11.38 in control plans Elderly primary care an increase of 2.2 - (Trivedi, copayment was $7.38 per 100 Moloo et al. and by an average of enrollees(95% CI, 2010) 95% increase 1.8–2.6) days of Elderly primary care an increase of 13.4 - hospital care (Trivedi, copayment was $7.38 per 100 enrollees Moloo et al. and by an average of per 100 enrollees

30

2010) 95% increase (95% CI, 10.2–16.6) Inpatient Elderly primary care a 0.7% absolute - care (Trivedi, copayment was $7.38 increase in the Moloo et al. and by an average of proportion of 2010) 95% increase enrollees (95% CI, 0.5%–1.0%) mental Older people Increased Use of mental - health aged ≥65 copayments from a health services services (Ndumele and mean of $14.43 to remained at 2.2% Trivedi 2011) $21.07 (6.64, 46%) decreased utilization rates - copayments from a were 1.2% mean of $25.00 to decreased $8.33 ($16.67,200%) prescription general total deductible from - out-of-pocket drug population $500 to $1000 spending from (Zuckerman, ($500;100%) $587 to $621 Shang et al. ($34;6%) 2010) out-of-pocket - out-of-pocket spending limit is from spending from $4,000 to $5,000 $621to $657 ($1000;25%) ($36; 6%) Coinsurance from - out-of-pocket 10% to 20% spending from $657 to $683 ($26;4%) Private health insurance In this review, private health insurance includes managed care (included HMO, PPO, IPA, PPO, POS, PFFS), employer-based insurance, Blue Cross, Blue Shield Association and other commercial health insurance programs. For inpatient services A study found that increased coinsurance had no significant effect on the employees and their dependents of GIC(Lischko 2008) in US. But a 10% increase in coinsurance rate in 1797 health insurance societies of Japan, decreased both the number of case (−6.96% ) and services (−4.66% ) for the insured employees(Babazono, Tsuda et al. 2003). For mental health Increased both coinsurance and copayment had little effect on the demand or utilization of mental health. For outpatient visits Changes of cost sharing affected the outpatient utilization for both the general patients and those with chronic diseases. For example, a 10% increase in coinsurance for patients with hypertension or diabetes resulted in a decreased of 7% compliance rate in the employee health insurance system of USA (Babazono, Miyazaki et al. 2005).

Table 15: Outpatient and inpatient services changes on cost sharing method

Health population Cost sharing Change of health Changes of services method change utilization financial risk or drugs inpatient employees From zero to $200, increased slightly (.0009 -

31 service and/or in-network $200, days per member per dependent of out-of-network month) not statistically GIC in US $300 significant (Lischko 2008)

Employees in From 10% to 20% Case rate: estimated Medical cost 1,797 health copayment; change was −6.96% per day: insurance Number of serviced day −3.15% societies and 150 Yen (1.25 per case: estimated dollars in 1997) for change was −4.66% Medical cost Japan each drug per insured: prescription −14.08% (Babazono, Tsuda et al. 2003) dental care Employees in From 10% to 20% Case rate: −5.77% Medical cost 1,797 health copayment; per day: insurance Number of serviced day: −11.48% societies and 150 Yen (1.25 per case −1.82% dollars in 1997) for Medical cost Japan each drug per insured: prescription −18.11% (Babazono, Tsuda et al. 2003) mental federal workers Coinsurance from have little impact on - health and their 20%-30% for consumer demand for services families High-option plan, outpatient mental health from 25%-40% for services (Carolyn A. low-option plan Watts 1986)

employees the $5 increase in A small (.0035 visits - and/or co-payment from pmpm) but statistically dependent of 2002 to 2003 significant decrease in GIC utilization (Lischko 2008)

Company From 80% roughly 18% more - employees coinsurance to $10 likely to initiate copayment treatment (Lindrooth, Lo Sasso et al. 2005) outpatient Employees in From 10% to 20% Case rate: −4.79% Medical cost visits 1,797 health copayment; per day: insurance Number of serviced day −13.00% societies and 150 Yen (1.25 per case: −5.67% Medical cost dollars in 1997) for per insured: Japan each drug −21.54% prescription (Babazono, Tsuda et al.

32

2003)

patients with Coinsurance Diabetic patients with - hypertension or increase from 20% no complications diabetes to 30% decreased 7% (83.7% to mellitus 66.7%) , the decrease for Hypertensive patients (Babazono, and diabetic patients Miyazaki et al. with complications were 2005) not significant.

General Copayments A significant increase in - Enrollees number of unique From $20-$40 to a adolescent users of (Ciemens flat of $10 for visits substance use services 2004)

People with $22.89 (mean) lower adherence to SGA - mental disease medication, lower persistence with SGA (Gibson, Jing et medication al. 2010)

employees from no deductible a relatively large decline - and/or in 2002 to a single (.0108 visits per dependent of deductible or member per month) in GIC co-payment of outpatient surgery visits $75/quarter in 2003 but not statistically (Lischko 2008) significant

Employees of Increase Inpatients: the frequency of expenditures Society 10%-20% physician visits were per visit were managed health negative and statistically also negative. insurance in significant, The Japan elasticity of demand for physician services is (Kan and 0.055. Suzuki 2010)

For description drugs The change in drugs use was different due to health status of target population. For the enrolled patients with chronic diseases, a $10 increase in copayment decreased OH ADD use by 9.2% for patients with Diabetes(Roblin, Platt et al. 2005), statin adherence by 3%(Gibson, Mark et al. 2006), adherence for patients with Type 2 Diabetes by 4.2%-4.9%(Gibson, Jing et al. 2010). (Table 16) For the general enrolled in private health insurance, the change from 2-tier to 3-tier resulted in their total use of prescription drugs decreasing, switch rate increasing, discontinue use decreasing 2-8 times compared with the control group. (Table 17) Public drug insurance programs In Pharmaceutical Benefits Scheme (PBS) of Australia, several cost sharing policies had even been implemented, and some authors evaluated the effect of them. Peter McManus (1996) assessed the increased copayment from AU$11 to AU$15 in Nov 1990 and a AU$2.5 copayment for repatriation, which decreased the utilization of 33 both essential drugs and discretionary drugs. Hynd assessed cost sharing policy of PBS in 2005 for the general population and concessional beneficiaries respectively in 2008 and 2009. Compared with general beneficiaries, dispensing decreased of social security was larger from 1.8-9.4% for essential drugs(Roblin, Platt et al. 2005). Cost sharing policy change in Pharmacare of Italy(Fiorio and Siciliani 2010) and Germany(Winkelmann 2004), also reduced the prescription consumption and physician visits. Pharmacare insurance in British Columbia, Canada, changed its cost sharing methods from a copayment policy to coinsurance and deductible, and the physician visits and emergency CAE admissions were significantly increased(Dormuth, Maclure et al. 2008). (Table 18)

34

Table 16: use changes for the enrollees with chronic disease in private health insurance

Services or drugs population Cost sharing method change Change of use of drugs Changes of financial risk Oral Enrollees with Increased from $0 to >$20 per 30 days median $10 increase - Hypoglycemic Diabetes in copayment decreased OH (OH) ADD managed care ADD use by 9.2%. (Roblin, Platt et al. 2005) statin adherence Statin users in mean copayment is $15 and mean increase is $1.5 A $10 index copayment - (Gibson, Mark et employ-based (change:$1.5) increase was associated al. 2006) insurance with a 3% decrease in the odds of adherence statin adherence Continually user mean copayment is $12 and mean increase is $6.0 A $10 increase in statin cost - (Gibson, Mark et of statin in (change:$6) sharing was associated with al. 2006) employ-based 11.9% decrease in the odds insurance of adherent for continuing users. Adherence Patients With Copayment increased from $10 to $20 to $30 $10 increased copayment, - (Gibson, Jing et al. Type 2 Diabetes (change: $10) 4.2%-4.9% adherence 2010) in employ-based decreased insurance Lescol or Lipitor Enrollees with A 10% increase in the relative copayment reduces choosing by as little - (Esposito 2003) chronic disease (change:10%) as 0.4% to 4.5% Adherence of employees and generic medications from $5 to 0; brand-name from 1.86% (p=0.134) - inhaled dependents with drugs from $28.55 to fell 29.9% points for inhaled corticosteroids and chronic (change:$5) corticosteroids to diabetes approximately 4% medications (p<0.001) points for (Chernew, Shah et diabetes medications al. 2008) Price Elastics: –0.11 to –0.20 Diabetes Enrollees with Copayment from tie1 $10, tie2 $20, tie3 $30 to Diabetes prescription drug expenditures for diabetes services prescription drug Diabetic unique $10; use increased by increased by 16% -32%

35 use and adherence Mail-ordered copayment from tie1 $20, tie2 $40, 5.5%-9.5%; (Nair, Miller et al. tie3 $80 to unique $20 mean adherence increased 2009) (Change:$10-$20) by 7%-8% Total PMPM days privately insured from the3-tier copayment design to a 4-tier 1.64 days PMPM smaller cost increased 7.5% for the intervention and used of 3-tiers with chronic coinsurance: than no changed group (P = and 3.0% comparison groups; total (Klepser, Huether the3-tier: 0.004); spending per member increased 6.3% et al. 2007) $10/$25/$40 utilization of tier-3 PMPM (from $72.29 to $76.87), , in 4 tier: antihypertensives (P = the intervention group versus a 9.5% 25%($5-$25)/ 0.031) and tier-3 PMPM increase (from $61.54 to 25%($25-$50)/50%($50-$75)/25%($50-$100) statins (P = 0.029) differed $67.41) in the comparison group, a out-net 50%($150-$300) significantly from the relative difference of $1.30 PMPM (P = comparison group. 0.013).

Table 17: drug use changes for the enrollees in private health insurance population Cost sharing method Change of use of drugs Changes of financial risk change Enrolled in Managed from a 2-tier to a 3-tier : Elasticity of demand for drugs was generally low, −0.16 - care Plan 1 from $5/$10 to to −0.10, for asymptomatic conditions; and moderate, (Pamela B. Landsman, $5/$15/$25; Plan 2: from −0.60 to −0.24, for symptomatic conditions. Winnie Yu et al. 2005) $10/$20 to $10/$20/$40; medication possession ratios decreased for cases and Plan 3: from $5/$10 to increased for controls ； $5/$20/$35; Plan4: Switch rates increased for cases and decreased for (control ) $10/$20 controls for all classes but CCBs. Discontinuation-rate changes for cases were 2 to 8 times those for controls. Insured in PPO (2) From 2-tier to 3-tier prescription tier 3 claims for intervention group from - (Fairman, Motheral et al. copayment: generic drugs 0.81 to 0.68(year1) and 0.79( year 2); for comparison 2003) from $7 to $8, brand drugs group from 0.82 to 0.86(year1) and 1.05( year 2); from $12 to $15 for prescription total claims for intervention group from

36

formulary brand, $25 for 8.46 to 9.32 (year1) and 10.56 ( year 2);for comparison nonformulary brands group from 8.63 to 9.87 (year1) and 11.20 ( year 2) Enrollees in total deductible from $500 to - out-of-pocket spending from $585 to $622 employer-sponsored $1000 health insurance out-of-pocket spending limit - out-of-pocket spending from $622 to $683 (Zuckerman, Shang et is from $4,000 to $5,000 al. 2010) Coinsurance from 10% to - out-of-pocket spending from $683 to $708 20% Working population of a $10 copayment increase Low-Sedating Antihistamines (LSA) use : copayment - public employer increase $7.23(a 41% increase), a 14.8% increase in (Meissner;, Moore; et al. utilization of LSAs and an 11.8% increase in the number 2004) of patients using LSAs, nasal steroids (NS): actual average copayment increase was $10.98 (71%), an 11.3% decrease in utilization of NSs and a 10.2% decrease in the number of users Elderly HMO members From $1 in 1987 to $3 in Increased copayment resulted in fewer total days of the change in prescription drug cost of (Johnson, Goodman et 1988 to $5 in 1989-1991 per exposure to cardiac agents and diuretics. diuretics was significant, but small al. 1997) dispensing. (change:$2) Enrollees in 97 managed generic drugs: from $7 to fewer days of drug use Increases in out-of-pocket drug prices reduce health plans $11; spending on drugs (Martin Gaynor 2006) preferred branded drugs: from $13 to $24 Non-preferred drugs from $17 to $38 per prescription.

37

(change: $4-$12) Employees between 18 Deductible from $50 to $100 price elasticity of demand: average the copayment increase was an $11 and 64 years in for person, from $100 to －0.269 for multisource brand-name drugs; －0.032 for reduction in prescription drug payments per HMO,PPO,POS $200 for family; single-source brand-name drugs employee per quarter; single-source (Gibson and R 2005) copayment from $2 for per for single-source brand-name drugs and generic drug, brand-name drugs were about $8 lower per prescription to $2 for generic utilization from a small decrease to much larger; quarter than without the copayment increase ， drug and $7 for brand drug; for multisource brand-name drugs : a steep reduction multisource brand-name drugs and generic cap from $500 to $750; in use drugs were no different coinsurance from 20% to 10% (mixed changes) the population covered increased by at least $25 (per Adherence: No changes; - by Scott & White Health 30-day fill) patients on anti-inflammatory agents for discontinuing Plan(HMO) therapy was 2.53 in the intervention versus control (Kim, Rascati et al. groups 2011) Employees in a large Generic drug copayment Mean copayment(SD) 1998 $17.09 (4.06) to 1999 $25.11 - firm(HMO) from $5 in 1998 to $10 in (2.23) Change 46.9%, total of LSA (Low-Sedating (Meissner;, Moore; et al. 1999; (change $5) Antihistamines) and NS (Nasal Steroids)prescriptions 2004) preferred drugs from $15 to increased 8.9%; $25; (change $10) Mean copayment(SD) changed from 1998 $17.59 (4.37) non-preferred drugs from to 1999 $24.82 (1.24) Change 41.1%, no. of LSA Rxs $25 to $35 (change $10) from 1998 3,241 to 1999 3,721; change14.8%; Mean copayment(SD) from $15.39 (1.95)in 1998 to $26.37 (4.30) in 1999, Change71.3%, no. of NS Rxs was from 957 in 1998 to 849 in 1999; change -11.3%.

38

Table 18: use change on cost sharing policy in drug insurance programs

population Cost sharing method Use Changes after cost sharing Changes of Financial risk Prescription All residents enrolled in from A$3.70 to $4.60 ($0.9;24%) Prescription counts: - counts Australian for concessional beneficiaries and For all beneficiaries, Atypical antipsychotics Pharmaceutical Benefits from $23.10 to $28.60 ($5.5;245) monthly increased 4.6%, Combination asthma Scheme (PBS) for general beneficiaries medicines, Proton-pump inhibitors (PPIs) and (Anna Hynd, Elizabeth Statins decreased monthly 7.6%, 9% and 4.9%; E. Roughead et al. 2009) For general population, Atypical antipsychotics monthly increased 8.6%, Combination asthma medicines, Proton-pump inhibitors (PPIs) and Statins decreased monthly 4.9%, 5.1% and 0.5%; For Concessional beneficiaries, Atypical antipsychotics monthly increased 2.9%, Combination asthma medicines, Proton-pump inhibitors (PPIs) and Statins decreased monthly 9.5%, 9.6% and 5.6%; DDD/1,000/day(daily dose per 1,000 population per day)\ for all beneficiaries, Antipsychotics: decreased by 0.4% per month. Combination asthma medicines: decreasing by 1.2% per month. Dispensings of PPIs: fell by 13% immediately, and the decreased by a further 0.5% per month after this time point. Statins: dispensing decreased by 10% immediately,

39

although the monthly increase in dispensing did not change. dispensing of All residents enrolled in Co-payments increased from For the social security beneficiaries, large - medicines Australian AUD$3.70 to $4.60 ($0.9; 24%) reductions in dispensing of combination asthma Pharmaceutical Benefits for social security beneficiaries medicines, osteoporosis treatments, PPIs and Scheme (PBS) and from $23.10 to $28.60 non-aspirin antiplatelets were 9.9%, 10.4%, 10.9% (Anna Hynd, Elizabeth ($5.5;245) for general and 10.7%; E. Roughead et al. 2008) beneficiaries in 2005. for general beneficiaries, large reductions in dispensing of combination asthma medicines, osteoporosis treatments, PPIs were 10.7%, 7.3%,8.3%. Compare with general beneficiaries, dispensings decreased of social security are larger from1.8– 9.4%. level of All residents enrolled in increased from $A11 to $A15 Community series - prescriptions Australian （ $4;36% ） for the general For discretionary drugs , a 10.4% significant Pharmaceutical Benefits population ，a $A2.50 co-payment decrease (p < 0.001) in the level of prescriptions Scheme (PBS) was required for Repatriation. For essential drugs, a 5.3% significant decrease (p < (McManus, Donnelly et 0.001) in the level of the series of prescriptions. al. 1996) Repatriation series: For discretionary drugs , a 5% significant decrease (p < 0.001) in the level of prescriptions For essential drugs, a 3.6% significant decrease (p < 0.001) in the level of the series of prescriptions. doctor visits the insured in DM 9 for small, DM 11 for number of doctor visits dropped of 9–10% after - Pharmacare, statutory medium and DM 13for large sizes copayment raised ；a drop ranging from 7 to 13%

40

health insurance, compare with control group Germany (Winkelmann 2004) number of all insured in between 1 and 4 Euro one Euro increase reduces the per capita number of one Euro increase reduces prescriptions Pharmacare, statutory prescriptions by 4% ；a reduction in the co-payment per capita public health insurance, in Italy by one Euro increased the per capita number of pharmaceutical expenditure (Fiorio and Siciliani prescriptions by 3.4% by 3.4% ； 2010) a reduction in the co-payment by one Euro increased per capita public pharmaceutical expenditure by 4.9%. Prescription Older Patients Copayment: Population Trends in Inhaler Use after copayment - drug aged >=65 enrolled in Can $10 or Can $25 per and deductible declined, inhaled steroids (-12.3%), Public drug insurance prescription up to an annual inhaled anticholinergics (-12.2%), inhaled plan in Canada ceiling of Can $200 or Can $275, 132-agonists (-5.8%). (Dormuth, Glynn et al. depending on annual family Mean monthly inhaled steroid use was 6.0% lower 2006) income ； (P < 0.01), inhaled 132-agonist use was 1.8% lower Deductible and ceiling: (P < 0.05), and inhaled anticholinergic use was a deductible of 0%, 1%, or 2% of 10.0% lower (P < 0.01). their annual income, after which Predictors of Initiating Inhaled Steroids after cost they paid 25% of prescription sharing, Patients with a new diagnosis of asthma or costs until reaching an annual COPD were 25% (95% CI, 14%-31%) less likely , ceiling of 1.25%, 2%, or3% of to initiate treatment with inhaled steroids, their income Lower-income patients were 17% (95% CI, 11%-24%).

41

Predictors of Ceasing Inhaled Steroids, Patients covered by the copayment policy were 47% (95% CI, 40%-55%) more likely to cease using inhaled steroids, Patients covered by the coinsurance plus deductible policy were 21% (95% CI, 15%-29%) . Prescription people over 65 years old From copayment to deductible emergency CAE admissions increased significantly - drugs enrolled in British and coinsurance: in the policy intervention group; physician visits has Columbia Pharmacare From $25 per prescription to a an increase of 3% both in copayment period and IBD insurance(drug) deductible for family of 0-2%, period. (Dormuth, Maclure et 25% coinsurance for >2% al. 2008) deductible, a ceiling of 1.25%, 2%,3% of income.

42

5.3.3 Effect of different levels of cost sharing methods Generally the different levels of cost sharing will be used for the same health services or medications to different population based on their income or health status, and the health insurance benefit package usually include different cost sharing levels for different health services; drug benefit programs always make different levels of cost sharing for different tiers. In this review, 54 included studies described or evaluated the effects of cost sharing by comparing different levels of cost sharing methods applied in health insurance schemes. For outpatient and inpatient services Only 5 articles analyzed how the different levels of cost sharing affect the utilization in private health insurance schemes . Moderate and high cost sharing reduced the use of outpatient service, care seeking, inpatient treatment and primary care. (Table 19) For example, in 21 employer health insurance groups of 45 states and the District of Columbia US(Stein and Zhang 2003), the receipt of any outpatient special substance abuse treatment was 22% and 38% less in the middle and high cost sharing for the enrolled adult compared with those in low cost sharing groups.

Table 19: use changes of health service in different level cost sharing policy

Health services population Cost sharing Change of health utilization method Receipt and 18 years and 10-50% of the Compare with low cost sharing: number of older billed amount, or Receipt 22% and 38% less in moderate outpatient enrolled in $0-25 per session and high cost-sharing specialty 41 benefit for outpatient Used number were fewer(P<0.05 in substance abuse plans moderate, P<0.01 in high ) treatment (Stein and Zhang 2003) Disease-modifying Enrollees in low For care of serious symptoms: the therapy (DMT) for a private copayment(≤50%), high-copay group was less likely multiple sclerosis health high (OR=0.22, P=.0001) to seek care than (MS) insurance copayment(≥50%)) the no-copay group, but the low- and (Avi and William no-copay groups did not differ 2010) (OR=0.80, P=.15). anti-hypertensive hypertension low: $5, medium: persistence to therapies: treatment patients $5–30, high: >$30 Analyses of 381,661 patients found (Yang, Kahler et receiving for <90-day significantly lower 3-month and al. 2011) SPC therapy supply; 6-month persistence to therapies with enrolled in a low: $10, medium: high copayments; commercial $10–60, Medication use: health high: >$60 for Relative to high-copayment drugs, insurance ≥90-day supply risk-adjusted odds ratios at 3 months were 1.29 (95% [CI]: 1.26, 1.32) and 1.27 (95% CI: 1.24, 1.30) for low- and medium-copayment medications, respectively. Physicians’ Visits Elderly in Mean charges For general seniors : drug charges had (Grootendorst and Ontario drug ranged from $0 to virtually no effect on the number of Levine 2002) program in, $26.62 physician visits. For social assistance 43

Health services population Cost sharing Change of health utilization method Canada recipients ： a 1% increase in drug charges was associated with a –0.03% decrease in visits. cancer screening Adults man Copayment: low Male patients in health plans with a services enrolled in ($1-10), and high copayment over $10 (OR = 0.38, 95% (Liang, Phillips et MEPS-HC, ($11+). CI: 0.19-0.78) or with deductibles over al. 2004) a private Deductibles: low $250 (OR = 0.38, 95% CI:0.23-0.62) health ($1-250), and high were significantly less likely to receive insurance ($251+). PCS than men in plans with no or Co-insurance lower copayments and deductibles. rate: low General men facing low copayments (1%-19%), and ($1-10) and low deductibles ($1-250) high (20%-100%) were most likely (87%-93%) while men facing high copayments ($11+) and high deductibles ($251+) were least likely (49%-67%) to receive PCS. GP, Physiotherapy, The insured Two types of Price Elasticity of Demand: prescription drugs, in Private deductibles ①: 0, comparing different levels of medical specialist, health 20, 50, 100, or deductible (101-350, 351-750, hospital, and other insurance, 150% of 751-1250, 1251-1750, >1750Dfl) with care Netherland premiums; the lowest level (0-100Dfl), the (Vliet 2004) ② : 0, 200, 500, elasticity is -0.14, -0.15, -0.09, -0.10 1000, 1500, or and -0.20 respectively, on average is 2000Dfl per year; -0.14. Elasticity for different care: GP, -0.40; Physiotherapy, -.032; prescription drugs, -0.08; medical specialist, -0.12; hospital, -0.04; and other care, -0.21; Hospitalization, Patient with Prescription: FFS higher than non-FFS in hospital days, asthma $5.20 (FFS plans) utilization. For hospitalization , 0.08 outpatient visit enrolled in and $8.64 and 0.05, respectively; for hospital (William, Ernst et MarketScan (non-FFS plans); days , 0.36 and 0.26, respectively; for al. 2003) private Outpatient Visit: outpatient visit , 5.46 and 1.40, insurance, $7.71 (FFS plans) respectively.( measured by annualized U.S. and $8.10 per beneficiary asthma-related health (non-FFS plans); care utilization) Emergency room visit: $10.24 (FFS plans) and $13.03 (non-FFS plans); Inpatient visit: $16.12 (FFS plans) and $2.78 (non-FFS plans); Drug use changes Not a few of the articles analyzed the drug use changes between different levels of cost sharing for the target population which includes general enrolled population, elderly, patients with chronic disease. (Table 20) In Medicare , Gilman (2007) compared different effects on the beneficiaries of one tier system and three-tier system, and found that the use of description drugs in one-tier system was more than three-tier system but the proportion of generic was lower. For financial risk, average annual drug cost for beneficiaries in one-tier system was higher, but despite

44

20 percent higher total expenditures, average out-of-pocket spending among enrollees in one-tiered plans was nearly half of the amount paid by beneficiaries in three-tiered plans(Gilman and Kautter 2007; Gilman 2008). In private health insurance scheme s, most of the authors got the similar outcomes that different levels of cost sharing had a positive relationship with the use of generic drug products, but the effects on prevalence, frequency, and expenditure rates was not consistent. People with higher copayment or deductible were likely to use more generic drugs (Thomas, Wallack et al. 2002; Deborah A. Taira 2006; Mager and Cox 2007). The tiered copayment drug plans may influence the selection of medication. But for the patients with chronic diseases such as heart failure or diabetes, lower adherence of medication resulted from higher copayment would increase risk of hospitalization(Cole, Norman et al. 2006; Colombi, Yu-Isenberg et al. 2008). In these studies, two authors defined the cost sharing levels as low, medium and high (the low was $0-10, medium was $11-19, high was $20), and both of them analyzed the medication adherence for the target patients with chronic diseases. But the results were a little different: for the patients with diabetes, 20% and 19% lower medication adherence for the elderly and general patients in high copayment group compared with those in low copayment(Colombi, Yu-Isenberg et al. 2008); but for the patients with a high copayment, the adherence to statin treatment were 42-44% lower than those who had a low copayment(Ye, Gross et al. 2007). Moral hazard According to Toyama (2009)’s study, for seniors over 65 years, higher levels of prescription drug cost sharing actually decrease inappropriate drug use with a relatively inelastic price elasticity of demand of -0.024 (p=0.004). Reducing the use of potentially inappropriate medications, implied that cost sharing had a positive effect on this aspect of quality(Gemmill-Toyama and Costa-Font 2009).

45

Table 20: drug use changes between different levels of cost sharing

Health insurance population Cost sharing method Change of health utilization Change of financial risk schemes Medicare General population One tier: $5/$10 Overall prescriptions use, one-tiered plans Average annual drug costs (Gilman and 3 tier: $5-10 generic; $15-20 were 7.6% (45.5% to 37.9 %) more for beneficiaries in Kautter 2007) preferred; $30-35 prescriptions and 4.9% (38.9% to 43.8 %) one-tiered plans were generic drugs used less than three-tier $2,188, compared with enrollees over 12-month period. $1,823 among members of three-tiered plans. Medicare retired Medicare enrollees A 1 tier system (with $5 and $10 A 10% increase in copayments for drug A 10% increase in (Gilman 2008) copayments), equivalents was associated with a 2.0% copayments for drug a 3-tier system (with reduction in the number of prescriptions equivalents was associated $5/$15/$25,$10/$15/$30, and filled, and a 0.7% reduction in proportion of with a 16.0% increase in $10/$25/$35 copayments) prescriptions filled with generics. out-of-pocket A 10% increase in copayment differentials expenditures. between drug equivalents was associated with A 10% increase in a 1.0% reduction in the number of copayment differentials prescriptions filled, and a 0.7% increase in between drug equivalents proportion of prescriptions filled with was associated with a 4.1% generics. increase in out-of-pocket expenditures. 32 drug plans patients with arthritis Copayment for cyclo-oxygenase For all patients with arthritis, Copayments for - (Briesacher, (COX-2)-selective inhibitors varied COX-2 prescriptions exceeding $15 lowered Kamal-Bahl et al. from $1 to $24 in 1-tier plans, $8 to the odds of any drug use relative to 2004) $20 in 2-tier plans and $10 to $31 copayments of $5 or less, and the odds (OR,

46

in 3 tier plans. 0.36; 95%CI, 0.26-0.49) of using COX-2 selective inhibitors were significantly lower compared with patients with 1-tier drug coverage. five drug benefit ambulatory children Plan A : Number of prescriptions: - plans in PPO younger than 18 years of G $2.00; B $8.00 Plan A 842; Plan B 1330; Plan C 890; Plan D (Hong and age Plan B: 3451; Plan E 2034 Shepherd 1996) G $2.00; B $8.00 Frequency of prescriptions: Plan C: Plan A 3.5; Plan B 4.8; Plan C1.5; Plan D 4.0; G$4.00;B $100% Plan E 2.8 Plan D: G$3.00;B $10.00 or 20% Plan E: G$4.00 B $10.00 or 20% G :Generic B: Brand Express Scripts enrollees of the drug $0 to $5, $6 to $10, $11 to $15, $16 Compared with plan sponsors that had a $0 to - Inc (ESI) plan benefit plans to $20, and $21+ $5 differential between generic and brand (private) copayments, plans with $11 to $15, $16 to (Mager and Cox $20, and $21+ differentials had GFRs that 2007) were 1.9%, 2.9%,and 5.2% higher on average, respectively (all P < .001). (GFR: Generic Fill Rate) Commercial patients aged 18–64 no special information of levels a $1 increase in brand drug copayment - health insurance reduces monthly days of supply by a little less (Thiebaud, Patel than 0.9%, and a $1 increase in generic

47 et al. 2008) copayment leads to a monthly reduction of 1.6% . Managed care aged 65 and older with PPO and indemnity plan: Discontinuation in drug use: the greater - (Deborah A. Taira chronic diseases deductible $600, but higher discontinuation among high-deductible 2006) coinsurance and drug CDHP enrollees in the two drug classes； copayment($10 generic; $20 low-deductible CDHP enrollees were preferred; $30 non-preferred); significantly less likely than others to Low-Deductible discontinue asthma medication ； Consumer-Driven Health Plans Utilization of generic drug: High-deductible (CDHP) : higher deductible CDHP enrollees were more likely to increase $1500-$2000, 15%coinsurance and generic use in one of five drug classes. no drug copayment; High-Deductible CDHP : highest deductible $1500-$3000, 15% coinsurance no drug copayment Self-insured aged 65 and older Plan 1: 1-tier, <$10 Moderate copayment resulted in a - employer health Plan 2: 2-tier, $5/$10 combination of purchasing less costly generic insurance plans Plan 3: 2-tier, $5/$15 drugs and purchasing more drugs through (Thomas, Wallack Plan 4: 3-tier, $5/$15/$25 mail order, which results in lower et al. 2002) Plan 5: 3-tier, $9/$9/$18 expenditures; Plan 6: 1-tier, 20% or less Higher copayment levels are associated with Plan 7: 1-tier, 50% or less a modest decrease in use for plans. Plan 8: 3-tier, 10%/20%/40% Kaiser patients (aged ≥65 years) Generic-only benefit: a $10 COPD patients with a generic-only benefit - Permanente with COPD copayment for each generic had taken less than the prescribed amount of Senior Advantage prescription a regular medication (OR=1.70; 95% CI,

48

(KPSA) Single-tier copayment: ranged 1.25-2.31) and stopped taking one or more of (Spence, Hui et al. from $0 to $10; their regular medications (OR=1.77; 2006) Two-tier copayment : a $5 or $10 CI,1.27-2.47) copayment for generics and a$10, (COPD: chronic obstructive pulmonary $15, or $20 copay for brand disease) medications. Private health aged 20 and above who different level according to different For each $10 rise in copayments, average - insurance initiated CL plan compliance in a plan-year falls by 5 (Goldman, Joyce (Cholesterol-lowering) percentage points ( P < .01). et al. 2006) therapy Compliance fell in all risk groups when copayments doubled from $10 to $20 (P < .05 for all risk groups). Compare with a $10 copayment baseline: full compliance increased 9 percentage points among the high-risk group (62% to 71%) and 10 percentage points among the medium-risk group (59% to 69%), and decreased from 52% to 44% among the low-risk group. Managed care Enrolled received a tier 1 $5 generic ； Relative to medications in tier 1, the adjusted - (Deborah A. Taira medical diagnosis of tier 2 $20 preferred branded ； odds ratio for compliance with medications in 2006) hypertension tier 3 from $20 to $165 tier 2 was 0.76 (95% CI = 0.75, 0.78), and for non-preferred branded medications in tier 3 it was 0.48 (95% CI = 0.47, 0.49) commercial Patients with The median copayment was $15.00 A $10 increase in copayment was - and/or Medicare CHF(Chronic heart for ACE inhibitors and $10.00 for associated with a 2.6% decrease in the supplemental failure) b-blockers. MPR (95% confidence interval [CI] 2.0–

49 plans 3.1%) among patients using ACE (Cole, Norman et inhibitors and a 1.8% decrease (95% CI al. 2006) 1.4–2.2%) among those using b-blockers. Among patients taking ACE inhibitors , the 2.6% decrease in MPR/$10 increase in copayment predicted a 6.1% increased risk of hospitalization for CHF (95% CI 0.5–12.0%). For those taking b-blockers, the 1.8% decrease in MPR/$10 increase in copayment predicted an 8.7% increased risk of hospitalization for CHF (95% CI 3.8–13.8%). PPG Industrial Adult with Diabetes low (US$0–9), medium (US$10– Medication Adherence : Total health care health plan 19), or high (US$20) age groups ≥65 years ， 84% low, 77% expenditure in the low (Colombi, medium, 64% high (P <0.0001) copayment group was 22% Yu-Isenberg et al. <65 years; 74% low, 71% medium, 55% high lower than in the high 2008) (P < 0.0001) copayment group (P Hospitalization risk =0.0239), amounting to a 36% lower among patients in the low saving of US$3116 per copayment group compared with those in the patient per year. high copayment group for patients ≥65 (P =0.0122). Comprehensive, Adult low, <$10; medium, ≥$10 but <$20; compared with those who had a mean - EPO, Noncap high, ≥$20 (in US dollars). copayment <$10, patients with a mean POS, PPO copayment of ≥$20: (Ye, Gross et al. were less than half as likely to be adherent to

50

2007) statin treatment (odds ratio [OR] 0.44; 95% CI, 0.38–0.51). the similar results by multivariate logistic analysis is 0.42; The mean MPR (medication possession ratio) significantly lower (mean difference = 0.12; 95% CI, 0.10–0.14; P < 0.001)

51

6 Discussion

6.1 Main results in this review

Three main outcomes of this review include how cost sharing policy can improve health utilization, control moral hazard and reduce financial risk produced. 6.1.1 Improve Health utilization One of the purposes of cost sharing is to change the utilization of services or prescription drugs for the enrollee of public or private health insurance schemes. Compared with people in insurance scheme without cost sharing, the introduction of cost sharing decreased the utilization of most kinds of medical services. For example, the National Health Insurance in Taiwan, China, outpatient copayment policy decreased the total number use of the drugs and people by 16.87% and 9% compared with non-cost sharing group(Liu and Romeis 2003; Liu and Romeis 2004); in Rand health insurance experiment, the utilization of most medical services were lowered by 50% for the general population compared with free plan(Newhouse 1984). Different levels of cost sharing could bring different extent of changes in health services utilization. Generally, higher cost sharing caused more decrease, for example, in Stein’s (2003) study, one coinsurance outpatient policy was introduced for the adult enrollee of 41 benefit plans (social managed care), and compared with those in low cost sharing group, receipt of outpatient specialty substance abuse treatment was 22% and 38% less in moderate and high cost sharing(Stein and Zhang 2003). Consequently, to increase or decrease the level of cost sharing could change the beneficiaries’ behavior. For example, after increasing cost sharing for the general population enrolled in NHI Taiwan, the outpatient visits and hospital visits decreased significantly(Huang and Tung 2006; Chen, Schafheutle et al. 2009). For the poor who applied for Medicaid, increased cost sharing were followed by significant decreased prescription drug utilization(Lurk, DeJong et al. 2004). But the changes may depend on which kind of the beneficiaries were influenced, and the elderly or those with chronic diseases were less likely to be influenced. For example, for the elderly enrolled in Medicare, decreasing copayment from a mean of $25 to $8.33($16.67, 200%) for the mental health resulted in the utilization rates decreasing by 1.2%(Ndumele and Trivedi 2011). For different kinds of populations, one cost sharing policy would have different effects. For example, Quebec drug plan applying a 25% coinsurance with the annual maximum of $200, and it was found that welfare recipients were more sensitive to this policy than the general elderly: for general prescription drugs use, welfare recipients’ utilization was reduced by 15.94% per day and the utilization of elderly people was reduced by 9.14%; emergency department visit rates increased by 54.2 per 10000 person-months for the welfare recipients and increased 14.2 by the elderly people(Tamblyn, Laprise et al. 2001). 52

At the same time, cost sharing method can be looked as a tool to change the price of service or drugs, but the price elastic of service or drugs is not at the same level. For example, a $10 increase in copayment decreased oral hypoglycemic ADD use by 9.2% for the enrollees with diabetes in a managed care plan(Roblin, Platt et al. 2005); a $10 index copayment increase was associated with a 3% decrease in the odds of adherence for statin in a employ-based insurance, but a 4.2%-4.9% decrease in adherence for patients with Type 2 Diabetes(Gibson, Mark et al. 2006); for each $10 rise in copayment, average compliance Cholesterol-lowering therapy in a plan-year fell by 5 percentage points for the adults(Goldman, Joyce et al. 2006). 6.1.2 Control Moral hazard Prescription cost sharing policy seems as a successful tool to control moral hazard both in private health insurance schemes and Medicare. In private health insurance, one of the purposes of cost sharing policy is to control moral hazard by decreasing over consumption of high price drugs and improve the use of generic drugs. The frequently used method is different tiers prescription copayment policy, in which usually one-tiered system was with lowest copayment, two-tiered system with moderate copayment and three-tiered system with highest prescription copayment. Different prices for generic and brand drugs among different tiered systems. And there were some positive effects showing that the consumption of generic drugs increased in both single-tired and three-tiered groups, especially higher proportion in the three-tiered system. The similar result was found in different levels of copayment policy. For example, in Mager and Cox(2007)’s study, compared with plan sponsors that had a $0 to $5 differential copayments for generic and brand drugs, plans with $11 to $15, $16 to $20, and $21+ differentials had generic fill rates that were 1.9%, 2.9%,and 5.2% higher on average, respectively(Mager and Cox 2007). Another study conducted by Saito(2010) analyzed the moral hazard rate of different levels of copayment (<$5; $5; $5-$15; $15; >$15) for patients with type 2 diabetes, and found that each $5 increase in copayment was associated with decreased rates of switching to a relatively more expensive drug (hazard ratio [HR]=0.49, 95% confidence interval [CI]=0.43,0.56) and an increased rate of switching to drugs of equal or lesser cost (HR = 1.04, 95% CI = 1.03, 1.05)(Saito, Davis et al. 2010). In public health insurance, the prescription copayment policy is also an effective instrument to control moral hazard, for example, Gilman (2007,2008) compared different effects of one tier system and three-tier system for the Medicare beneficiaries, and found that the proportion of generic drugs use was higher in three-tier system group than one-tier system group(Gilman and Kautter 2007; Gilman 2008). Nelson (1984) and Lurk (2004) concluded that a small (50) copayment for prescription service was a successful mechanism to control the cost and assist in financing Medicaid prescription drug program (Nelson, Jr et al. 1984; Lurk, DeJong et al. 2004).

53

At the same time, prescription drug cost sharing also decreased use of essential drugs or adherence to medications which induced adverse effects on vulnerable population such as the poor, the elderly and patients with chronic diseases. For example, after a deductible and a 25% coinsurance charge was introduced in the Canadian province of Quebec in 1996 , use of essential drugs decreased by 9.12% in elderly persons and by 14.42% in welfare recipients ; use of less essential drugs decreased by 15.14% and 22.39%, respectively. And emergency department visit rates related to reduction in the use of essential drugs also increased by 14.2 per 10000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). The rate (per 10000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9)(Tamblyn, Laprise et al. 2001). For the patients with chronic diseases such as heart failure or diabetes, lower adherence of medication followed by higher copayment would increase risk of hospitalization(Cole, Norman et al. 2006; Colombi, Yu-Isenberg et al. 2008). But outpatient cost sharing policy seems produce two-side effects. Some studies showed that the implementation of outpatient cost sharing policy was not followed by adverse effects. For example, John Hsu (2006) showed that among commercially insured subjects, ED visits decreased by 12 percent with the $20–35 copayment (95% CI: 11-13%), and 23 percent with the $50-100 copayment (95 %CI: 23–24 %) compared with no copayment. Hospitalizations, ICU admissions, and deaths did not change with copayments. And the study concluded that relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events(Hsu, Price et al. 2006). Selby (1996) The introduction of a small copayment for the use of the emergency department in a health maintenance organization was associated with a decline of about 15 percent in the use of that department, mostly among patients with conditions which were considered as likely not to present an emergency(Selby, Fireman et al. 1996). But some other studies validated that cost sharing policy had negative effects on the vulnerable population, such as the people with chronic disease, disabled, and so on. For example, relatively small copayments were associated with significantly lower mammography rates among women who should undergo screening mammography according to accepted clinical guidelines in Medicare managed-care plans(Trivedi, Rakowski et al. 2008). After a $50 copayment for ED visit implemented in Oregon Health Plan (Medicaid) in 2003, ED visits of OHP beneficiaries fell from 38% to 32%, and the proportion of psychiatric visits covered by OHP fell from 41% to 31%. These findings suggest a worrisome reduction in access to medical care for uninsured Oregonians and unstable access for OHP enrollees, especially for those with behavioral health conditions(Lowe, McConnell et al. 2006). Hopkins(1975) found that respondents who had the most chronic diseases and conditions in their household were those most likely to claim that copayment affected their care(Hopkins, Roemer

54 et al. 1975). 6.1.3 Financial risk changes The other role of cost sharing policy is to change financial burden of the target population, especially in public health insurance schemes. In developing countries, the beneficiaries of health insurance schemes had lower financial risk than the uninsured because they only need to pay part of the cost of health services or drugs. A hospital outpatient 20% and inpatient 20-80% policy in New Cooperate Medical Scheme (NCMS) in China rural decreased catastrophic out of pocket payments of the intervention group from 8.98% to 8.25%(Sun, Sukhan et al. 2009); a 20% coinsurance in the social health insurance, Vietnam, reduced the financial risk of the insured by 16 and 18%(Ardeshir, Sisira et al. 2006); a RWF 100 (US$ 0.30) co-payment per episode of illness in health centres in Micro-health insurance schemes in Rwanda also reduced the financial risk for the beneficiaries(Pia and Kara 2006). But Huang and Tung (2005) studied the effect of increased copayment from $5.12 to $6.00 in National Health Insurance, and concluded that the increase in co-payment significantly affects visit frequency, but did not reduce overall pharmaceutical costs. The net effect of raising co-payment for drugs is simply shifting a larger share of the burden of pharmaceutical costs from the NHIB to patients(Huang and Tung 2006). In developed countries, most of the authors concluded that out of pocket spending of beneficiaries was increased because of cost sharing policy. Two studies about Medicare got the similar results. Zuckerman (2010) concluded that in a Medigap supplemental insurance 100% increase in deductible, 25% increase in ceiling, 10% increase in coinsurance for description drugs were followed by 4%-6% increased out-of-pocket spending among the general enrolled. In studies of Gilman(2007,2008), it was found that despite 20 percent higher in total expenditures, average out-of-pocket spending among enrollees in one-tiered plans was nearly half the amount paid by beneficiaries in three-tiered plans. Cost sharing policy induced different effects on the beneficiaries in Medicaid. In Jay Helms’s study (1978), the average expenditure of per Medical eligible person per quarter increased by 3% and overall program cost increased by 3-8%; Jared T. Lurk (2004) investigated that the increased description and outpatient copayment decreased the utilization and cost to the clinics, but did not significantly influenced patients’ out of pocket costs. And Nelson (1984) showed that average monthly expenditure in cost sharing groups was lower (48c) than no copayment group, and this study concluded that a small (50) copayment for prescription service was a successful mechanism to control the cost and assist in financing a Medicaid prescription drug program. In the public drug insurance program, British Columbia Pharmacare in Canada, general elderly financial risk changed a lot after cost sharing policy, for example, for the elderly with rheumatoid arthritis (RA), their out-of-pocket payments increased from C$119.5 to C$229.8(Li, Guh et al. 2007). 55

In private health insurance schemes, the total health care spending were also lowered because of the introduction of cost sharing policy(Anderson, Brook et al. 1991), but for the beneficiaries the financial risk increased. For example, comparing free plan with 95% cost sharing plan, Manning (1987) found that the per capita expenses on the free plan were 45 percent higher, drug expenditures per person on the free care plan were about 60% higher found by Foxman (1987), and dental expenses were 46% higher, which was slightly more than twice as much was spent by participants with free care found by Manning, Bailit et al. (1985). Especially for the vulnerable population, the average yearly out-of-pocket payment in emergency department by High Deductible Health Plan members increased from $8 in the baseline year to $49 in the follow-up period compared with $9 in both periods for members in control group(Wharam, Landon et al. 2007).

6.2 Significance of this review

For health policy makers, there are rich materials which could be gained from this systematic review. In this study, we included all kinds of health insurance schemes which practiced cost sharing policy. And according to our analysis, they played different roles to control moral hazard and change financial risk. We synthesize the key information from the included studies based on three categories of cost sharing policy implementation: a new introduction of cost sharing, changes (decrease or increase) of cost sharing levels, different levels of cost sharing methods. These could be matched to different phrases of health policy making. Even few studies were found in developing counties, but health policy makers from these countries should learn more from the experiences of the high income countries. At first, cost sharing could be an effective tool to avoid over consumption of some kind of drugs and services. Higher cost sharing will be used if the government wants to control the utilization of some services, and this also would be useful to control the cost of health insurance schemes. The strategy of introduction of a cost sharing policy or increase the level of present cost sharing could be used by the government. Secondly, lower cost sharing policy could improve some necessary services utilization or low price drugs. For the vulnerable population, the government could make lower cost sharing policy to encourage them to use some medical or preventive services by reducing their financial risk burden. Thirdly, different levels of cost sharing policy should be considered by the policy makers. The price elastic is different for different drugs and services which mean different effects of cost sharing policy. Fourthly, impoverished population is more sensitive than the general population to cost sharing policy. Target population of cost sharing policy should be considered seriously; otherwise some unexpected adverse effects will happen. Lastly, it is a big challenge for the policy makers to balance the moral hazard and

56 financial risk for the populations. To control moral hazard, the higher cost sharing policy will probably induce higher financial burden for the target population especially the vulnerable population. To decrease the financial risks for the target population, lower cost sharing policy will usually be followed by over consumption of health services. One of the strategy should be considered by the policy makers is to analyze the risk level or health status of the target population: lower cost sharing level to those with the higher risk of diseases; higher cost sharing policy for those with lower risk of diseases.

6.3 Limitation of this review

From this review we only found 11studies in developing countries which include India(1), Uganda(2), Israel(1), Kyrgyzstan(1) and Taiwan, China(6). Most of them are cross sectional studies which used the databases data to analyze the use changes of health services or drugs after the cost sharing policy implemented. Also some key information of cost sharing was not very clearly described by the authors. And the study time is limited no more than one year. So some deep analysis of the effects of cost sharing methods used in developing counties was needed, especially high quality and long term research. At the same time, in this systematic review, some controlled studies were found such as Rand health insurance experiment study, controlled before and after studies and time series studies, which could be the good basic to conduct a evaluative systematic review.

57

Acknowledgement

This review work was financially supported by the Alliance for Health Policy and Systems Research (AHPSR), the World Health Organization. The team would thank Dr Sandy Oliver and Dr Claire Stansfield from University of London for the contributions to development of the protocol. Thanks to Dr. Bhupinder Kaur Aulakh from the AHPSR for editing the report. We are grateful to Ms Yang Bingyi, Mr Ma Dongping, Mr Zhang Guojie, Mr Yu Haining and Mr Chang Jie from Center for Health Management and Policy of Shandong University for their help in collection of the literature.

58

Reference

Anderson, G. M., R. Brook, et al. (1991). "A comparison of cost-sharing versus free care in children: effects on the demand for office-based medical care." Med Care 29 (9): 890-898. Andrew J. Karter, M. M. P., Howard H. Moffet, Ameena T. Ahmed, James Chan, PharmD, Michele M. Spence, Joe V. Selby, and Susan L. Ettner (2007). "Effect of Cost-sharing Changes on Self-monitoring of Blood Glucose." Am J Manag Care(13): 408-416. Anna Hynd, Elizabeth E. Roughead, et al. (2009). "Increased patient co-payments and changes in PBS-subsidised prescription medicines dispensed in Western Australia." Australian and new zealand journal of public health 33 (3): 246-252. Anna Hynd, Elizabeth E. Roughead, et al. (2008). The impact of co-payment increases on dispensings of government-subsidised medicines in Australia. P. a. D. Safety. Ardeshir, S., S. Sisira, et al. (2006). "Does non-profit health insurance reduce financial burden? Evidence from the Vietnam living standards survey panel." Health Economics 15 (6): 603-616. Augurzky, B., T. K. Bauer, et al. (2006). "Copayments in the German health system-Do they work." RWI: Discussion Papers 43 : 2002. Avi, D. and E. William (2010). "How Does Cost-Sharing Affect Drug Purchases? Insurance Regimes in the Private Market for Prescription Drugs." Journal of Economics & Management Strategy 19 (3): 545-574. Babazono, A., M. Miyazaki, et al. (2005). "Effects of the increase in co-payments from 20 to 30 percent on the compliance rate of patients with hypertension or diabetes mellitus in the employed health insurance system." Int J Technol Assess Health Care 21 (2): 228-233. Babazono, A., T. Tsuda, et al. (2003). "Effects of an increase in patient copayments on medical service demands of the insured in Japan." International Journal of Technology Assessment in Health Care 19 (3): 465-475. Blais, L., J. Couture, et al. (2003). "Impact of a cost sharing drug insurance plan on drug utilization among individuals receiving social assistance." Health Policy 64 (2): 163-172. Briesacher, B., S. Kamal-Bahl, et al. (2004). "Three-tiered-copayment drug coverage and use of nonsteroidal anti-inflammatory drugs." Archives of Internal Medicine 164 (15): 1679-1684. Burnham, G. M., G. Pariyo, et al. (2004). "Discontinuation of cost sharing in Uganda." Bulletin of the World Health Organization 82 (3): 187-195. Carolyn A. Watts, R. M. S., and Nicholas P. Jewell (1986). "Demand for Outpatient Mental Health Services in a Heavily Insured Population: The Case of the Blue Cross and Blue Shield Association's Federal Employees Health Benefits Program." Health Serv Res(21): 267-289. Chen, C.-S., T.-C. Liu, et al. (2007). "The effect of Taiwan's National Health Insurance on infants' preventive care use and inpatient care use." Health Policy 80 (3): 432-443. Chen, L. C., E. I. Schafheutle, et al. (2009). "The impact of nonreferral outpatient co-payment on medical care utilization and expenditures in Taiwan." Research in Social and Administrative Pharmacy 5(3): 211-224. Chernew, M., M. Shah, et al. (2008). "Impact Of Decreasing Copayments On Medication Adherence Within A Disease Management Environment." Health Affairs 27 (1): 103.

59

Ciemens, E. L. (2004). "The effect of parity-induced copayment reductions on adolescent utilization of substance use services " J.Stud. Alcohol 65 (6): 731-735. Claudia, P. t. and H. Christian (2006). "Optional deductibles in social health insurance systems." The European Journal of Health Economics 7(4): 225-230. Cole, J. A., H. Norman, et al. (2006). "Drug copayment and adherence in chronic heart failure: effect on cost and outcomes." Pharmacotherapy 26 (8): 1157-1164. Colombi, A. M., K. Yu-Isenberg, et al. (2008). "The effects of health plan copayments on adherence to oral diabetes medication and health resource utilization." J Occup Environ Med 50 (5): 535-541. Criel, B., P. Van der Stuyft, et al. (1999). "The Bwamanda hospital insurance scheme: effective for whom? A study of its impact on hospital utilization patterns." Social Science & Medicine 48 (7): 897-911. Deborah A. Taira, K. S. W., Feride Frech-Tamas, Richard S. Chung. (2006). "Copayment level and compliance with antihypertensive medication: analysis and policy implications for managed care." Am J Manag Care(12): 678-683. Dormuth, C. R., R. J. Glynn, et al. (2006). "Impact of two sequential drug cost-sharing policies on the use of inhaled medications in older patients with chronic obstructive pulmonary disease or asthma." Clinical Therapeutics 28 (6): 964-978. Dormuth, C. R., M. Maclure, et al. (2008). "Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications." Clinical Therapeutics 30 (Part 1): 1038-1050. Dormuth, C. R., P. Neumann, et al. (2009). "Effects of prescription coinsurance and income-based deductibles on net health plan spending for older users of inhaled medications." Med Care 47 (5): 508-516. Esposito, D. (2003). 'You Get What You Copay For'--The Influence of Patient Copayments on the Demand for Drugs within a Therapeutic Class: The Case of the Statins, University of California, Santa Barbara. Ph.D. Fairman, K. A., B. R. Motheral, et al. (2003) "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." Clinical Therapeutics, 3147-3161. Farbmacher, H. (2009). Copayments for doctor visits in Germany and the probability of visiting a physician - Evidence from a natural experiment, University of Munich, Department of Economics. Fiorio, C. V. and L. Siciliani (2010). "Co-payments and the demand for pharmaceuticals: Evidence from Italy." Economic Modelling 27 (4): 835-841. Foxman, B., R. B. Valdez, et al. (1987). "The effect of cost sharing on the use of antibiotics in ambulatory care: Results from a population-based randomized controlled trial." Journal of Chronic Diseases 40 (5): 429-437. Gemmill-Toyama, M. and J. Costa-Font (2009). Does Cost Sharing Affect the Quality of Pharmaceutical Care for the Elderly?, HEDG, c/o Department of Economics, University of York. Gibson, B. and O. R. G. R (2005). "The Effects of Prescription Drug Cost Sharing: A Review of the Evidence." The American Journal Of Managed Care(11): 730-740. Gibson, T. B., Y. Jing, et al. (2010). "Cost-sharing effects on adherence and persistence for

60

second-generation antipsychotics in commercially insured patients." Managed Care 19 (5): 40-47. Gibson, T. B., T. L. Mark, et al. (2006). "The effects of statin copayments and statin adherence on medical care utilization and expenditures." Journal of the American College of Cardiology 47 (4): 263A-263A. Gibson, T. B., T. L. Mark, et al. (2006). "The effects of prescription drug copayments on statin adherence." American Journal of Managed Care 12 (9): 509-517. Gilman, B. H., and Kautter, J. (2008). Impact of Multitiered Copayments on the Use and Cost of Prescription Drugs among Medicare Beneficiaries. Health Research and Educational Trust. H. H. S. Research. Gilman, B. H. and J. Kautter (2007). "Consumer response to dual incentives under multitiered prescription drug formularies." Am J Manag Care 13 (6 Pt 2): 353-359. Goldman, D. P., G. F. Joyce, et al. (2006). "Varying pharmacy benefits with clinical status: the case of cholesterol-lowering therapy." Am J Manag Care 12 (1): 21-28. Grignon, M., M. Perronnin, et al. (2008). "Does free complementary health insurance help the poor to access health care? Evidence from France." Health Econ 17 (2): 203-219. Grootendorst, P. V. and M. Levine (2002). Do Drug Plans Matter? Effects of Drug Plan Eligibility on Drug Use Among the Elderly, Social Assistance Recipients and the General Population, McMaster University, Social and Economic Dimensions of an Aging Population Research Papers : 86 pages. Hong, S. H. and M. D. Shepherd (1996). "Outpatient prescription drug use by children enrolled in five drug benefit plans." Clinical Therapeutics 18 (3): 528-545. Hopkins, C. E., M. I. Roemer, et al. (1975). "Cost-sharing and prior authorization effects on Medicaid services in California: part I. The beneficiaries' reactions." Med Care 13 (7): 582-594. Hsu, J., M. Price, et al. (2006). "Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study." Health Serv Res 41 (5): 1801-1820. Huang, J. H. and C. M. Tung (2006). "The effects of outpatient co-payment policy on healthcare usage by the elderly in Taiwan." Arch Gerontol Geriatr 43 (1): 101-116. Jay, H., P. N. Jospeh, et al. (1978). "Copayments and Demand for Medical Care: The California Medicaid Experience." Bell Journal of Economics 9(1): 192-208. Johnson, R. E., M. J. Goodman, et al. (1997). "The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members." Health Serv Res 32 (1): 103-122. Jowett, M., P. Contoyannis, et al. (2003). "The impact of public voluntary health insurance on private health expenditures in Vietnam." Social Science & Medicine 56 (2): 333-342. Kan, M. and W. Suzuki (2010). "Effects of cost sharing on the demand for physician services in Japan: Evidence from a natural experiment." Japan and the World Economy 22 (1): 1-12. Keeler, E. B. (1992) "Effects of cost sharing on use of medical services and health." J. Med. Pract. Manage., 11-15. Keeler, E. B. and J. E. Rolph (1983). "How cost sharing reduced medical spending of participants in the health insurance experiment." Jama 249 (16): 2220-2227. Kim, J., S. Ko, et al. (2005). "The effects of patient cost sharing on ambulatory utilization in South

61

Korea." Health Policy 72 (3): 293-300. Kim, Y. A., K. L. Rascati, et al. (2011). "Retrospective evaluation of the impact of copayment increases for specialty medications on adherence and persistence in an integrated health maintenance organization system." Clinical Therapeutics 33 (5): 598-607. Kipp, W., J. Kamugisha, et al. (2001). "User fees, health staff incentives, and service utilization in Kabarole District, Uganda." Bulletin of the World Health Organization 79 (11): 1032-1037. Klepser, D. G., J. R. Huether, et al. (2007). "Effect on drug utilization and expenditures of a cost-share change from copayment to coinsurance." J Manag Care Pharm 13 (9): 765-777. Koc, C. (2005). "Health-Specific moral hazard effects." Southern Economic Journal 72 (1): 98-118. Leibowitz, A., W. G. Manning, et al. (1985) "The demand for prescription drugs as a function of cost-sharing." Social science & medicine (1982), 1063-1069. Li, X., D. Guh, et al. (2007). "The impact of cost sharing of prescription drug expenditures on health care utilization by the elderly: Own- and cross-price elasticities." Health Policy 82 (3): 340-347. Liang, S. Y., K. A. Phillips, et al. (2004). "Does patient cost sharing matter? Its impact on recommended versus controversial cancer screening services." Am J Manag Care 10 (2 Pt 1): 99-107. Lindrooth, R. C., A. T. Lo Sasso, et al. (2005). "The effect of expanded mental health benefits on treatment initiation and specialist utilization." HSR: Health Services Research 40:4 August 2005 : 1092-1107. Lischko, A. (2008). Cost sharing: Do employees understand cost sharing and do increases in cost sharing really have an impact on the utilization of health care services? United States -- Massachusetts, Boston University. Sc.D.: 215. Liu, S. Z. and J. C. Romeis (2003). "Assessing the effect of Taiwan's outpatient prescription drug copayment policy in the elderly." Medical Care 41 (12): 1331-1342. Liu, S. Z. and J. C. Romeis (2004). "Changes in drug utilization following the outpatient prescription drug cost-sharing program - evidence from Taiwan's elderly." Health Policy 68 (3): 277-287. Lowe, R. A., Fu, R,Gallia, C. A. (2010). "Impact of policy changes on emergency department use by Medicaid enrollees in Oregon." Med Care 48 (7): 619-627. Lowe, R. A., K. J. McConnell, et al. (2006). "Changes in access to primary care for Medicaid beneficiaries and the uninsured: the emergency department perspective." Am J Emerg Med 24 (1): 33-37. Lurk, J. T., D. J. DeJong, et al. (2004). "Effects of changes in patient cost sharing and drug sample policies on prescription drug costs and utilization in a safety-net-provider setting." American Journal of Health-System Pharmacy 61 (3): 267-272. Mager, D. E. and E. R. Cox (2007). "Relationship between generic and preferred-brand prescription copayment differentials and generic fill rate." Am J Manag Care 13(part 2) : 347-352. Manning, W. and M. Marquis (1996). "Health insurance: the tradeoff between risk pooling and moral hazard." Journal of Health Economics 15 : 609-639. Manning, W., J. Newhouse, et al. (1987). "Health insurance and the demand for medical care:

62

evidence from a randomized experiment." Am Econ Rev 77 (3): 251-277. Manning, W. G., H. L. Bailit, et al. (1985). "The demand for dental care: evidence from a randomized trial in health insurance." J Am Dent Assoc 110 (6): 895-902. Manning, W. G., Jr., K. B. Wells, et al. (1986). "How cost sharing affects the use of ambulatory mental health services." Jama 256 (14): 1930-1934. Martikainen, J. E., U. Hakkinen, et al. (2007) "Adoption of new antiglaucoma drugs in Finland: impact of changes in copayment." Clinical Therapeutics, 2468-2476. Martin Gaynor, J. L., William B. Vogt. (2006). Is Drug Coverage A Free Lunch? Cross-Price Elasticities And The Design Of Prescription Drug Benefits. Martin, S. (2001). "The effect of variable health insurance deductibles on the demand for physician visits." Health Economics 10 (5): 441-456. McManus, P., N. Donnelly, et al. (1996). "Prescription drug utilization following patient co-payment changes in Australia." Pharmacoepidemiol Drug Saf 5(6): 385-392. Meissner;, B., W. M. Moore;, et al. (2004). "Effects of an Increase in Prescription Copayment on Utilization of Low-Sedating Antihistamines and Nasal Steroids." J Manag Care Pharm 10 (3): 226-233. Nair, K. V., K. Miller, et al. (2009). "Prescription copay reduction program for diabetic employees: Impact on medication compliance and healthcare costs and utilization." American Health and Drug Benefits 2(1): 14-24. Ndumele, C. D. and A. N. Trivedi (2011). "Effect of Copayments on Use of Outpatient Mental Health Services Among Elderly Managed Care Enrollees." Medical Care 49 (3): 281-286. Nelson, A. A., Jr, et al. (1984). "The effect of a Medicaid drug copayment program on the utilization and cost of prescription services." Medical Care(8): 724-736. Newhouse, J. P. (1984). Cost Sharing for Medical Care Services. , The Rand Corporation. Newhouse, J. P., W. G. Manning, et al. (1981) "Some interim results from a controlled trial of cost sharing in health insurance." New England Journal of Medicine, 1501-1507. O'Brien, B. (1989). "The effect of patient charges on the utilisation of prescription medicines." Journal of Health Economics 8(1): 109-132. O'Grady, K. F., Manning, W. G,Newhouse, J. P,Brook, R. H (1985). "The impact of cost sharing on emergency department use." N Engl J Med 313 (8): 484-490. Pamela B. Landsman, Winnie Yu, et al. (2005). "Impact of 3-Tier Pharmacy Benefit Design and Increased Consumer Cost-sharing on Drug Utilization ". Paul, V. G., K. M. John, et al. (2004). The Impact of Differential Cost Sharing of Non-Steroidal Anti-Inflammatory Agents on the Use and Costs of Analgesic Drugs, McMaster University. Pia, S. and H. Kara (2006). "Horizontal equity in utilisation of care and fairness of health financing: a comparison of micro-health insurance and user fees in Rwanda." Health Economics 15 (1): 19-31. Reeder, C. E. and A. A. Nelson (1985). "The differential impact of copayment on drug use in a Medicaid population." Inquiry 22 (4): 396-403. Roblin, D. W., R. Platt, et al. (2005). "Effect of increased cost-sharing on oral hypoglycemic use in five managed care organizations - How much is too much?" Medical Care 43 (10): 951-959. Saito, E. P., J. W. Davis, et al. (2010). "Copayment level and drug switching: Findings for type 2

63

diabetes." Am J Pharm Benefits 2(6): 412-420. Saksena, P., A. l. F. Antunes, et al. (2011). "Mutual health insurance in Rwanda: Evidence on access to care and financial risk protection." Health Policy 99 (3): 203-209. Schmitt, J., W. Kirch, et al. (2009). "Effects of the introduction of the German "Praxisgebuhr" on outpatient care and treatment of patients with atopic eczema." Journal Der Deutschen Dermatologischen Gesellschaft 7(10): 879-886. Schneeweiss, S., A. R. Patrick, et al. (2007). "Adherence to beta-blocker therapy under drug cost-sharing in patients with and without acute myocardial infarction." American Journal of Managed Care 13 (8): 445-452. Sedjo, R. L. and E. R. Cox (2008). "Lowering Copayments: Impact of Simvastatin Patent Expiration on Patient Adherence." American Journal of Managed Care 14 (12): 813-818. Selby, J. V., B. H. Fireman, et al. (1996) "Effect of a copayment on use of the emergency department in a health maintenance organization." New England Journal of Medicine, 635-641. Spence, M. M., R. Hui, et al. (2006) "Cost reduction strategies used by elderly patients with chronic obstructive pulmonary disease to cope with a generic-only pharmacy benefit (Brief record)." Journal of Managed Care Pharmacy, 377-382. Stein, B. D. and W. Zhang (2003). "Drug and alcohol treatment among privately insured patients: rate of specialty substance abuse treatment and association with cost-sharing." Drug and Alcohol Dependence 71 (2): 153-159. Sun, X., J. Sukhan, et al. (2009). "Catastrophic medical payment and financial protection in rural China: evidence from the New Cooperative Medical Scheme in Shandong Province." Health Economics 18 (1): 103-119. Tamblyn, R., R. Laprise, et al. (2001). "Adverse events associated with prescription drug cost-sharing among poor and elderly persons." Jama-Journal of the American Medical Association 285 (4): 421-429. Thiebaud, P., B. V. Patel, et al. (2008). "The demand for statin: The effect of copay on utilization and compliance." Health Economics 17 (1): 83-97. Thomas, C. P., S. S. Wallack, et al. (2002). "Impact of health plan design and management on retirees' prescription drug use and spending, 2001." Health Affairs 22 (1): W408-W419. Trivedi, A. N., H. Moloo, et al. (2010). "Increased ambulatory care copayments and hospitalizations among the elderly." N Engl J Med 362 (4): 320-328. Trivedi, A. N., W. Rakowski, et al. (2008). "Effect of cost sharing on screening mammography in Medicare health plans." N Engl J Med 358 (4): 375-383. Vardy, D. A., T. Freud, et al. (2006). "Introducing co-payment for consulting specialist services." Israel Medical Association Journal 8(8): 558-562. Vliet, R. C. J. A. v. (2004). "Deductibles and Health Care Expenditures: Empirical Estimates of Price Sensitivity Based on Administrative Data." International Journal of Health Care Finance and Economics 4(4): 283-305. Waters, T. M., C. F. Chang, et al. (2011). "Impact of high-deductible health plans on health care utilization and costs." Health Serv Res 46 (1 Pt 1): 155-172. Wharam, J. F., B. E. Landon, et al. (2007). "Emergency department use and subsequent hospitalizations among members of a high-deductible health plan." Jama 297 (10): 1093-1102.

64

William, H. C., R. B. Ernst, et al. (2003). Benefit Plan Design and Prescription Drug Utilization Among Asthmatics: Do Patient Copayments Matter?, National Bureau of Economic Research, Inc. Winkelmann, R. (2004). "Co-payments for prescription drugs and the demand for doctor visits - Evidence from a natural experiment." Health Economics 13 (11): 1081-1089. Yang, W., K. H. Kahler, et al. (2011). "Copayment level, treatment persistence, and healthcare utilization in hypertension patients treated with single-pill combination therapy." Journal of Medical Economics 14 (3): 267-278. Ye, X., C. R. Gross, et al. (2007). "Association between copayment and adherence to statin treatment initiated after coronary heart disease hospitalization: A longitudinal, retrospective, cohort study." Clinical Therapeutics 29 (12): 2748-2757. Zuckerman, S., B. Shang, et al. (2010). "Reforming beneficiary cost sharing to improve Medicare performance." Inquiry : a journal of medical care organization, provision and financing 47 (3): 215-225.

65

Annex1 Searching sources, strategies and results

Database: 3ie database of impact evaluations Search time : 30/ 06 /2011 Search strategy: "cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR copay OR co-pay OR co-payments OR copays OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee" Number of the searched :10 Number of related : 5

Database: Cochrane library Search time : 4 / 07 /2011 Search strategy: #1:MeSH descriptor Cost Sharing explode all trees OR (“cost sharing” OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee"):ti,ab,kw #2:("health care" OR "health service" OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR "pathology service" OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare ):ti,ab,kw AND (use OR utilization OR utilization OR access OR accessibility):ti,ab,kw #3:("physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR over-utilization OR over-utilizations OR over-utilisation OR over-utilisations OR "hospital admission" OR "hospital admissions"):ti,ab,kw #4:("financial risk" OR "financial risks" OR "financial burden" OR "financial burdens"):ti,ab,kw OR ((cost OR costs OR burden OR burdens OR expense OR expenses ):ti,ab,kw AND (illness OR illnesses OR sickness OR sicknesses OR disease OR diseases) :ti,ab,kw )) OR ("health expenditure" OR "health expenditures" OR "household expenditure" OR "household expenditures"):ti,ab,kw #5: #1AND (#2 OR #3 OR #4) Number of the searched :316 Database: Econlit Search time : 21/6/2011

66

Search strategy: ((AB "cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR OOP OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee" ) AND ((AB ( "health care" OR "health service" OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR "pathology service" OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare ) and AB ( use OR utilization OR utilisation OR access OR accessibility ) OR (AB "physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR over-utilization OR over-utilizations OR over-utilisation OR over-utilisations OR "hospital admission" OR "hospital admissions" ) OR (AB "financial risk" OR "financial risks" OR "financial burden" OR "financial burdens")OR (AB ( cost OR costs OR burden OR burdens OR expense OR expenses ) and AB ( illness OR illnesses OR sickness OR sicknesses OR disease OR diseases ))OR (AB "health expenditure" OR "health expenditures" OR "household expenditure" OR "household expenditures"))) OR ((TI "cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR OOP OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee" ) AND ((TI ( "health care" OR "health service" OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR "pathology service" OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare ) and TI ( use OR utilization OR utilisation OR access OR accessibility )) OR (TI "physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR over-utilization OR over-utilizations OR over-utilisation OR over-utilisations OR "hospital admission" OR "hospital admissions") OR (TI "financial risk" OR "financial risks" OR "financial burden" OR "financial burdens") OR (TI ( cost OR costs OR burden OR burdens OR expense OR expenses ) and TI ( illness OR illnesses OR sickness OR sicknesses OR disease OR diseases )) OR (TI "health expenditure" OR "health expenditures" OR "household expenditure" OR "household expenditures" ))) Number of the searched : 363

67

Database: ELDIS Search time : 29/ 06 /2011 Search strategy: "cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR copay OR co-pay OR co-payments OR copays OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee" Number of the searched :507 Number of related : 14

Database:EMBASE Search time : 04/ 07 /2011 Search strategy: (('cost sharing' or cost-sharing or coinsurance or co-insurance or deductibles or deductible or copayment or copayments or co-payment or co-payments or copay or copays or co-pay or co-pays or ceiling or ceilings or 'out-of-pocket payment' or 'out-of-pocket payments' or 'out-of-pocket expenditure' or 'out-of-pocket expenditures' or 'OOP' or 'out of pocket payment' or 'out of pocket payments' or 'out of pocket expenditure' or 'out of pocket expenditures' or 'user fee') .ti,ab,kw.)AND ((health care utilization/)OR ((health service/)OR(health care delivery/)OR('health care' or 'health service' or 'health services' or 'preventive service' or 'preventive services' or 'medical care' or 'medical service' or 'medical services' or 'ambulatory' or 'pathology service' or 'pathology services' or 'pharmaceutical service' or 'pharmaceutical services' or 'provider service' or 'provider services' or 'physician service' or 'physician services' or 'hospital care' or drug or drugs or prescription or prescriptions or medication or medications or medicine or medicines or healthcare) .ti,ab,kw.AND ('use' or 'utilization' or 'utilisation' or 'access' or 'accessibility') .ti,ab,kw.) OR ('physician visit' or 'physician visits' or 'outpatient visit' or 'outpatient visits' or hospitalization or hospitalized or hospitalisation or hospitalised or 'moral hazard' or 'adverse selection' or 'price elasticities' or 'price elasticity' or overutilization or overutilizations or overutilisation or overutilisations or over-utilization or over-utilizations or over-utilisation or over-utilisations or 'hospital admission' or 'hospital admissions') .ti,ab,kw. OR("cost of illness"/)OR('financial risk' or 'financial risks' or 'financial burden' or 'financial burdens') .ti,ab,kw.OR ((cost or costs or burden or burdens or expense or expenses) and (illness or illnesses or sickness or sicknesses or disease or diseases)) .ti,ab,kw.OR("health care cost"/)OR('health expenditure' or 'health expenditures' or 'household expenditure' or 'household expenditures') .ti,ab,kw.) Number of the searched :2410 Number of related :

Database: Global Health Library Search time : 29/ 06 /2011 Search strategy: 68

Title ："cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures " OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure " OR "out of pocket expenditures" OR "user fee" Number of the searched :49

Database: OpenGrey Search time : 30/ 06 /2011 Search strategy: "cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures " OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure " OR "out of pocket expenditures" OR "user fee" Number of the searched : 167 Number of releted : 11

Database: NTIS Search time : 30 / 06 /2011 Search strategy: Title:("cost sharing" OR cost-sharing OR deductible OR deductibles OR coinsurance OR co-insurance OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out of pocket" OR "user fee") OR Keyword:("cost sharing" OR cost-sharing OR deductible OR deductibles OR coinsurance OR co-insurance OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out of pocket" OR "user fee") Number of the searched : 1142 Number of related : 77

Database: IDEAS Search time : 05/ 07 /2011 Search strategy: (("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments)+( "health care" | " health service " | "health services" | "preventive service" | "preventive services" | "medical care")+( use | utilization | utilisation | access | accessibility))|( (copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+( "health care" | " health service " | "health services" | "preventive service" | "preventive services" | "medical care")+( use | utilization | utilisation | access | accessibility))|(("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments)+( "medical service" | "medical services" | ambulatory | " pathology service " | "pathology services" | "pharmaceutical service")+( use | 69 utilization | utilisation | access | accessibility))|((copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+( "medical service" | "medical services" | ambulatory | " pathology service " | "pathology services" | "pharmaceutical service")+( use | utilization | utilisation | access | accessibility))|(("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments)+("pharmaceutical services" | "provider service" | "provider services" | "physician service" | "physician services" | "hospital care" | drug | drugs) +( use | utilization | utilisation | access | accessibility))|((copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+("pharmaceutical services" | "provider service" | "provider services" | "physician service" | "physician services" | "hospital care" | drug | drugs) +( use | utilization | utilisation | access | accessibility))|(("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments)+( prescription | prescriptions | medication | medications | medicine | medicines | healthcare) +( use | utilization | utilisation | access | accessibility))|((copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+( prescription | prescriptions | medication | medications | medicine | medicines | healthcare) +( use | utilization | utilisation | access | accessibility))|(("cost sharing" | cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments)+( "physician visit" | "physician visits" | "outpatient visit" | "outpatient visits" | hospitalization | hospitalized | hospitalisation | hospitalised | "moral hazard" | "adverse selection" | "price elasticities" | "price elasticity"))|((copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket" | "user fee")+("physician visit" | "physician visits" | "outpatient visit" | "outpatient visits" | hospitalization | hospitalized | hospitalisation | hospitalised | "moral hazard" | "adverse selection" | "price elasticities" | "price elasticity"))|(("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments)+( overutilization | overutilizations | overutilisation | overutilisations | over-utilization | over-utilizations | over-utilisation | over-utilisations | "hospital admission" | "hospital admissions" | "financial risk" | "financial risks" | "financial burden" | "financial burdens"))|((copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+( overutilization | overutilizations | overutilisation | overutilisations | over-utilization | over-utilizations | over-utilisation | over-utilisations | "hospital admission" | "hospital admissions" | "financial risk" | "financial risks" | "financial burden" | "financial burdens"))|(("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments | copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+(cost | costs | burden | burdens | expense | expenses) + (illness | illnesses | sickness | sicknesses | disease | diseases))|( ("cost sharing" |cost-sharing | coinsurance | co-insurance | deductibles | deductible | copayment | copayments | co-payment | co-payments | copay | copays | co-pay | co-pays | ceiling |ceilings | out-of-pocket |"OOP" | "out of pocket " | "user fee")+("health expenditures" | "health expenditure" | "household expenditure" | "household expenditures")) Number of the searched : 6739 Number of releted : 162

Database: Popline Search time :2011-6-22 Search strategy: [subject] (cost sharing / cost-sharing / coinsurance / co-insurance / deductibles/ deductible / copayment / copayments / co-payment / co-payments / copay / copays / co-pay / co-pays / ceiling / ceilings / out-of-pocket

70 payment / out-of-pocket payments / out-of-pocket expenditure / out-of-pocket expenditures / OOP / out of pocket payment/out of pocket payments / out of pocket expenditure / out of pocket expenditures / user fee)&(( (health care / health service / health services / preventive service /preventive services / medical care / medical service / medical services / ambulatory / pathology service / pathology services / pharmaceutical service / pharmaceutical services / provider service / provider services / physician service / physician services / hospital care/ drug / drugs/ prescription / prescriptions / medication / medications / medicine/ medicines / healthcare)&(use/ utilization/ utilisation / access / accessibility)) /(physician visit / physician visits / outpatient visit / outpatient visits / hospitalization / hospitalized / hospitalisation / hospitalised / moral hazard / adverse selection / price elasticities / price elasticity / overutilization/ overutilizations / overutilisation / overutilisations / over-utilization / over-utilizations / over-utilisation / over-utilisations / hospital admission / hospital admissions)/( financial risk / financial risks / financial burden / financial burdens / ((cost / costs / burden/ burdens / expense / expenses)&(illness / illnesses / sickness / sicknesses / disease / diseases)) / health expenditure / health expenditures / household expenditure / household expenditures)) Number of the searched :179

Database: ProQuest Search time : 23/ 06 /2011 Search strategy: [Subject]("cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR copay OR co-pay OR co-payments OR copays OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR " out-of-pocket expenditure" OR "out-of-pocket expenditures " OR "OOP" OR " out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure " OR "out of pocket expenditures" OR "user fee")AND[Subject]((("health care" OR " health service " OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR "pathology service" OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare)AND(use OR utilization OR utilisation OR access OR accessibility))OR("physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR over-utilization OR over-utilizations OR over-utilisation OR over-utilisations OR "hospital admission" OR "hospital admissions" OR "financial risk" OR "financial risks" OR "financial burden" OR "financial burdens" OR "health expenditures" OR "health expenditure" OR "household expenditure" OR "household expenditures" OR ((cost OR costs OR burden OR burdens OR expense OR expenses)AND(illness OR sickness OR disease OR illnesses OR sicknesses OR diseases)))) Number of the searched :672

Database: PubMed Search time : 21/ 06 /2011 Search strategy:

71

("cost sharing"[MH] OR "cost sharing"[TIAB] OR cost-sharing[TIAB] OR "deductibles and coinsurance"[MH] OR coinsurance [TIAB] OR co-insurance [TIAB] OR deductibles[TIAB] OR deductible[TIAB] OR copayment [TIAB] OR copayments[TIAB] OR co-payment[TIAB] OR co-payments[TIAB] OR copay[TIAB] OR copays[TIAB] OR co-pay[TIAB] OR co-pays[TIAB]OR ceiling[TIAB] OR ceilings[TIAB] OR "out-of-pocket payment"[TIAB] OR "out-of-pocket payments"[TIAB] OR "out-of-pocket expenditure"[TIAB] OR "out-of-pocket expenditures"[TIAB] OR "OOP"[TIAB] OR "out of pocket payment"[TIAB] OR "out of pocket payments"[TIAB] OR "out of pocket expenditure"[TIAB] OR "out of pocket expenditures"[TIAB] OR "user fee"[TIAB]) AND "Health Services/utilization"[MH] OR (("Health Services"[MH] OR "Delivery of Health Care"[MH] OR "health care"[TIAB] OR "health service"[TIAB] OR "health services"[TIAB] OR "preventive service"[TIAB] OR "preventive services"[TIAB] OR "medical care"[TIAB] OR "medical service"[TIAB] OR "medical services"[TIAB] OR ambulatory[TIAB] OR "pathology service"[TIAB] OR "pathology services"[TIAB] OR "pharmaceutical service"[TIAB] OR "pharmaceutical services"[TIAB] OR "provider service"[TIAB] OR "provider services"[TIAB] OR "physician service"[TIAB] OR "physician services"[TIAB] OR "hospital care"[TIAB] OR drug[TIAB] OR drugs[TIAB] OR prescription[TIAB] OR prescriptions[TIAB] OR medication[TIAB] OR medications[TIAB] OR medicine[TIAB] OR medicines[TIAB] OR healthcare[TIAB]) AND ( use[TIAB] OR utilization[TIAB] OR utilisation[TIAB] OR access[TIAB] OR accessibility[TIAB])) OR "physician visit"[TIAB] OR "physician visits"[TIAB] OR "outpatient visit"[TIAB] OR "outpatient visits"[TIAB] OR hospitalization[TIAB] OR hospitalized [TIAB] OR hospitalisation[TIAB] OR hospitalised [TIAB] OR "moral hazard"[TIAB] OR "adverse selection"[TIAB] OR "price elasticities"[TIAB] OR "price elasticity"[TIAB] OR overutilization[TIAB] OR overutilizations[TIAB] OR overutilisation[TIAB] OR overutilisations[TIAB] OR over-utilization[TIAB] OR over-utilizations[TIAB] OR over-utilisation[TIAB] OR over-utilisations[TIAB] OR "hospital admission"[TIAB] OR "hospital admissions"[TIAB] OR "cost of illness"[MH] OR "financial risk" [TIAB] OR "financial risks" [TIAB] OR "financial burden" [TIAB] OR "financial burdens" [TIAB] OR ((cost[TIAB] OR costs[TIAB] OR burden[TIAB] OR burdens[TIAB] OR expense[TIAB] OR expenses[TIAB]) AND (illness[TIAB] OR illnesses[TIAB] OR sickness[TIAB] OR sicknesses[TIAB] OR disease[TIAB] OR diseases[TIAB])) OR "health expenditures"[MH] OR "health expenditure"[TIAB] OR "health expenditures"[TIAB] OR "household expenditure"[TIAB] OR "household expenditures"[TIAB]) NOT (letter[PT] OR news[PT] OR comment[PT] OR editorial[PT] OR bibliography[PT] OR resource guides[PT]) Number of the searched : 2066

Database: ScienceDirect Search time : 04/07/2011 Search strategy: (Tak("cost sharing" OR "cost-sharing" OR coinsurance OR "co-insurance" OR deductibles OR deductible OR copayment OR copayments OR "co-payment" OR "co-payments" OR copay OR copays OR "co-pay" OR "co-pays" OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee")) AND ((((Tak(illness OR illnesses OR sickness OR sicknesses OR disease OR diseases)) AND (Tak(cost OR costs OR burden OR burdens OR expense OR expenses))) OR (Tak("financial risk" OR "financial risks" OR

72

"financial burden" OR "financial burdens" OR "health expenditure" OR "health expenditures" OR "household expenditure" OR "household expenditures"))) OR ((Tak("physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR "over-utilization" OR "over-utilizations" OR "over-utilisation" OR "over-utilisations" OR "hospital admission" OR "hospital admissions")) OR ((Tak(use OR utilization OR utilization OR access OR accessibility)) AND (Tak("health care" OR "health service" OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR "pathology service" OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare))))) Number of the searched : 314

Database:Scopus Search time : 04/ 07 /2011 Search strategy: (TITLE-ABS-KEY("cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures" OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure" OR "out of pocket expenditures" OR "user fee")) AND (((TITLE-ABS-KEY(("health care" OR "health service" OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR "pathology service" OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare) AND (use OR utilization OR utilisation OR access OR accessibility))) OR (TITLE-ABS-KEY("physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR over-utilization OR over-utilizations OR over-utilisation OR over-utilisations OR "hospital admission"))) OR ((TITLE-ABS-KEY("financial risk" OR "financial risks" OR "financial burden" OR "financial burdens")) OR (TITLE-ABS-KEY((cost OR costs OR burden OR burdens OR expense OR expenses) AND (illness OR illnesses OR sickness OR sicknesses OR disease OR diseases))) OR (TITLE-ABS-KEY("health expenditure" OR "health expenditures" OR "household expenditure" OR "household expenditures")))) Number of the searched :3381

Database: Web of Science

73

Search time : 23/ 06 /2011 TS=("cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures " OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure " OR "out of pocket expenditures" OR "user fee") AND (TS=(("health care" OR " health service " OR "health services" OR "preventive service" OR "preventive services" OR "medical care" OR "medical service" OR "medical services" OR ambulatory OR " pathology service " OR "pathology services" OR "pharmaceutical service" OR "pharmaceutical services" OR "provider service" OR "provider services" OR "physician service" OR "physician services" OR "hospital care" OR drug OR drugs OR prescription OR prescriptions OR medication OR medications OR medicine OR medicines OR healthcare) AND ( use OR utilization OR utilisation OR access OR accessibility)) OR TS=("physician visit" OR "physician visits" OR "outpatient visit" OR "outpatient visits" OR hospitalization OR hospitalized OR hospitalisation OR hospitalised OR "moral hazard" OR "adverse selection" OR "price elasticities" OR "price elasticity" OR overutilization OR overutilizations OR overutilisation OR overutilisations OR over-utilization OR over-utilizations OR over-utilisation OR over-utilisations OR "hospital admission" OR "hospital admissions") OR TS=("financial risk" OR "financial risks" OR "financial burden" OR "financial burdens") OR TS=((cost OR costs OR burden OR burdens OR expense OR expenses) AND (illness OR illnesses OR sickness OR sicknesses OR disease OR diseases)) OR TS=("health expenditures" OR "health expenditure" OR "household expenditure" OR "household expenditures")) Number of the searched :1,365

Database: WHOLIS Search time : 22/ 06 /2011 Search strategy: "cost sharing" OR cost-sharing OR deductible OR deductibles OR coinsurance OR co-insurance OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out of pocket" OR out-of-pocket OR OOP OR "user fee"

Number of the searched : 19

Database: WHO Publication Search time: 29/ 06 /2011 "cost sharing" OR cost-sharing OR coinsurance OR co-insurance OR deductibles OR deductible OR copayment OR copayments OR co-payment OR co-payments OR copay OR copays OR co-pay OR co-pays OR ceiling OR ceilings OR "out-of-pocket payment" OR "out-of-pocket payments" OR "out-of-pocket expenditure" OR "out-of-pocket expenditures " OR "OOP" OR "out of pocket payment" OR "out of pocket payments" OR "out of pocket expenditure " OR "out of pocket expenditures" OR "user fee" Number of the searched: 3790 Number of related after screening: 39

74

Database: CNKI Search time :2011-9-19 Search strategy: (主题=成本分摊+成本分担+成本共付+部分分摊+部分分担+共同支付+自付+赔付+封顶线) AND ( 主题 =保健+医疗服务+卫生服务+健康服务+预防服务+药品服务+病理服务+住院服务+临床服务+医生访问 +门诊访问+就医+看病+住院+道德风险+逆向选择+价格弹性+过度利用+过度使用+经济风险+经济负 担+健康开销+健康花费+健康消费+疾病开销+疾病花费+疾病消费+看病开销+看病花费+看病消费+健 康成本+疾病成本+看病成本) AND ( 主题=医疗保险+健康保险+新农合+城镇居民医疗保险+城镇职工 医疗保险+新型农村合作医疗+大病救助+医疗救助) order by relevant Number of the searched :285 Number of releted : 0

Database: 万方 Search time :2011-9-19 Search strategy: (title=" 成本分摊"or" 成本分担"or" 成本共付"or" 部分分摊"or" 部分分担"or" 共同支付"or" 自付"or" 赔付"or" 封顶线" ) and (title=" 保健"or" 医疗服务"or" 卫生服务"or" 健康服务"or" 预防服务"or" 药品服务"or" 病理服 务"or" 住院服务"or" 临床服务"or" 医生访问"or" 门诊访问"or" 就医"or" 看病"or" 住院"or" 道德风险"or" 逆向 选择"or" 价格弹性"or" 过度利用"or" 过度使用"or" 经济风险"or" 经济负担"or" 健康开销"or" 健康花费"or" 健 康消费"or" 疾病开销"or" 疾病花费"or" 疾病消费"or" 看病开销"or" 看病花费"or" 看病消费"or" 健康成本"or" 疾病成本"or" 看病成本") and (title=" 医疗保险"or" 健康保险"or" 新农合"or" 城镇居民医疗保险"or" 城镇职 工医疗保险"or" 新型农村合作医疗"or" 大病救助"or" 医疗救助" ) Number of the searched :263 Number of releted : 0

75

Annex2 screen process and results

6904 123 excluded: they were opinion papers, letter, news, comment, editorial, or bibliography, etc. 6781

6063 excluded: they were not about health insurance and cost sharing.

718 141excluded: they were theoretical papers, not about implemented

42 the full texts of strategies or policies. 577 them cannot be 137 excluded: they were not about the retrieved introduction of cost sharing, change of cost sharing level, or the cancel of cost sharing. 440

222excluded: there were no outcomes about health care utilizations or financial burden of the participants.

218

176

76