Out-of-pocket (OOP) healthcare expenditure in India

Transcription

1 SPECIAL ARTICLE The High Cost of Dying Laishram Ladusingh, Anamika Pandey The cost of the inpatient care of decedents is much higher than that of survivors at all stages of life. The differential is significantly higher for those residing in rural areas, staying longer in hospitals, utilising private health facilities and suffering from chronic diseases. The difference is due to physicians in private hospitals prescribing more expensive drugs, subjecting patients to more clinical tests and higher charges on utilisation of amenities and facilities. The findings support the absolute income hypothesis that the economically better-off spend more on healthcare and the end-of-life care hypothesis that healthcare expenditure on efforts to save life is high. Laishram Ladusingh is with the International Institute for Population Sciences, Mumbai and Anamika Pandey is a PhD scholar at the International Institute for Population Sciences, Mumbai. 44 Out-of-pocket (OOP) healthcare expenditure in India constituted 4.8% of household consumption and 10.7% of household non-food expenditure in (Garg and Karan 2009) which escalated to 12.2% and 21.7% respectively in (Ladusingh and Pandey 2013). This is unprecedented and is one of the highest OOP expenditures in the world. In the Indian context an unexplored but alarming aspect of OOP healthcare expenditure is the high cost of decedents as compared to survivors. Little is known about how the cost of inpatient care of decedents differs from that of survivors cost by sex, residence background and types of disease. In this paper an attempt is made to fill this research gap and provide key inputs for strengthening the public health system and broadening the social security coverage. One of the earliest studies by Sutton (1965) has shown that 48% of all deaths occurred in short stay hospitals and 63% of these had used some hospital services, but did not provide information on treatment cost. In the US in 1997 per capita medicare paid to patients in the last year of life is six times the cost of that paid to survivors (Raphael et al 1993) while it was seven to one in 1988 (Lubitz and Riley 1993). Payne et al (2009) in a study in Canada found that during 1991 to 2001, the ratio of decedent to survivor costs have increased for all age groups, and were greatest for hospital and continuing care costs. About one-quarter of medicare outlays are for the last year of life and it remains unchanged from 20 years ago (Hogan et al 2001). Emanuel et al (2000) have found that for patients needing substantial care, 10% of household income was spent on healthcare, families had to cope with loans, second mortgages or take an additional job. In India 5.6% of households had to finance OOP healthcare expenditure by taking loans (Ladusingh and Pandey 2013). Ginzberg (1980) attributed the high cost of dying to disproportionate spending on patients who are terminally ill. The advancement in healthcare technology and availability of costly life-saving drugs have also contributed to inpatient care cost. Epidemiological transition too escalates inpatient OOP healthcare expenditure for decedents since most deaths are a result of chronic diseases and multi-organ failures. The decline in age-specific mortality rates over time postpones death to later ages pushing up the healthcare costs of dying (Seshamani and Garg 2004a). The relationship between age and time with death and health expenditure has been extensively studied for different countries by Seshamani and Garg (2004b), Stearns and Norton (2004), Zweifel et al (2004) and Werblow et al (2005). This study seeks to shed light on the high cost of inpatient care for the decedents in comparison to that of survivors in march 16, 2013 vol xlviii no 11 EPW Economic & Political Weekly

2 India by socio-demographic and types of disease of patients. It covers a broad spectrum of inpatient care, such as the duration of hospitalisation, medical and non-medical component of OOP expenditure, and comparison of cost of inpatient care between public and private health facilities. The other main objectives of this study are to test two main hypotheses: the end of life hypothesis and the absolute income hypothesis of healthcare expenditure. This study is the first of its kind in India and hopes to enrich literature on public health research. Data and Methods The data used in this study consists of 31,868 hospitalised cases of which 2.2% died as inpatients in the course of treatment. The source is the 60th round of National Sample Survey Office (NSSO, ) on morbidity and healthcare. It is a nationally representative household survey and a multi-stage stratified sampling design is adopted. For each member of the sampled representative households, details about age, sex, morbidity status of acute and chronic diseases, status of treatment and hospitalisation were collected. Further for each individual, episodes of ailment in the one-year period preceding the survey, treatment status, medical and non-medical OOP expenditures, duration of hospitalisation and public or private affiliation of health facilities utilised for treatment were collected using a semi-structured questionnaire. The concern that inpatient care expenditure is limited to hospital cost and does not give the full picture of the total cost according to Scitovsky (2005) is taken care of in this study by considering both medical and non-medical costs, fees and charges for clinical tests, transportation cost, cost of drugs and appliances, and expenditure towards food and lodging of the accompanying person. Descriptive statistics and bivariate analysis are employed to describe characteristics of inpatients and comparison of unadjusted mean OOP expenditure for inpatients care between decedents and survivors, between public and private health facilities and characteristics of inpatients. It is the annual OOP expenditure that has been considered in this study. A multilevel hierarchical model is used for OOP expenditure for inpatient care and analyse differential by survival status demographic and economic background, types of disease and public-private affiliation of health facility. During the one-year reference period an individual suffering from certain diseases may be hospitalised for inpatient care a number of times. For each episode of hospitalisation, the data provide medical and non-medical and other OOP expenditure for inpatient care together with the disease and other information. The types of disease in this study are grouped into chronic, acute and others. Items included in other medical expenditure and other charges together with grouping of diseases are provided in the Appendix (p 49). At the individual level the data has information on age, sex, survival status, residence background and economic status. Considering the clustering of episodes of hospitalisation for an individual a two-level hierarchical model is considered appropriate for modelling the OOP inpatient care expenditure. SPECIAL ARTICLE The multilevel model used in this study is of form Log(OOPE ij )=βo ij +β 1 x ij +e ij (1) βo ij = β0+uoj (2) where i denotes episode of hospitalisation for inpatient care, the j denotes an individual and OOPE ij the OOP expenditure for inpatient care for i th episode of j th individual. Explanatory variables x ij include variables measured at both episode and individual levels. In this random intercept model, the mean OOP expenditure (in log scale) for inpatient care varies by individuals and between episodes of hospitalisation. The random part of the model comprises the random terms, u 0j at the individual level and e ij at the episode level. Random terms are assumed to follow independent normal distributions, u 0j ~N(0, σ u 2 ) and e ij ~N(0, σ e 2 ). For estimation of model parameters MLWiN version 2.02 is used. Results and Discussion The gap in the mean OOP expenditure for inpatient care between decedents and survivors by age are shown in Figure 1. Two distinct features can be noticed. First, the mean OOP expenditure of decedents is significantly higher than that of survivors across age and second, the OOP inpatient care cost regardless of survival status at old age is still high but tends to drop. Figure 1: Mean Out of Pocket Expenditure for Inpatient Care of Decedents and Survivors by Age in India ( ) Further to examine differential in mean costs of inpatient care by types of diseases for decedents and survivors, Table 1 (p 46) shows the distribution of inpatients cross classified by survival status and types of disease. It is observed that 19% of the decedents sought inpatient care for treatment of cardiovascular diseases (CVD) followed by 16.3% for other chronic ailment, 11.6% for other diagnosed ailments, 8.4% for accidents, injuries burns and bone fractures. The inpatients that died of tuber culosis (TB), bronchial asthma, respiratory and those diseases of the ear, nose and throat and neurological disorder constitute 7.8%, 7.1%, 5.4% and 4.3% respectively of decedents. About 8% died of undiagnosed ailments. On the other hand, 15.5% of the survivors sought inpatient care for other chronic ailments and 16.8% for other diagnosed ailments. Survivors who were treated as inpatients for CVD, accidents, injuries, burns and bone fractures, fever and diarrhoea and dysentery constitute 9.2%, 9.8%, 7.7% and 7.4% respectively of survivors. While comparing the mean OOP health expenditure for inpatient care of decedents and survivors, the treatment costs for accidents, injuries, burns and bone fractures, CVD and diseases of kidney and urinary system are higher than that of other diseases, the cost incurred by decedents for treatment of Economic & Political Weekly EPW march 16, 2013 vol xlviii no Mean annual inpatient care cost (Rs) 20,000 15,000 10,000 5,000 Decedents Survivors

3 SPECIAL ARTICLE other chronic diseases and other diagnosed ailment not in the list is nearly double that of the OOP expenditure incurred by the survivors for these diseases while it is the other way round in the case of treatment of neurological disorders. It is obvious that for most ailments and diseases the mean OOP inpatient care expenditure of decedents is higher than that of the survivors. As there is no information about the seriousness and critical stages of the ailments and diseases, it is not possible to comment on whether spending more can save lives or not. However, it is clear from Figure 2 that among the decedents who died in the and 60 years and above groups, the cause of death was chronic diseases. Table 1: Distribution of Inpatients by Disease and Mean Annual Out-of-Pocket Expenditure by Survival Status of Hospitalised Cases in India ( ) Disease Groups % N % N Mean Inpatient Care Decedents Survivors Decedents Survivor Expenditure (in Rs) Decedents Survivors Fever of unknown origin ,074 5,820 2,882 Diarrohea/dysentery ,542 3,953 1,729 Bronchial asthma ,199 4,102 Respiratory including ear/nose/throat ,896 4,555 Accidents/injuries/burns/fractures/poisoning ,020 9,489 9,609 Other acute ailment ,888 7,901 3,809 Gastritis/gastric/peptic ulcers ,634 21,680 5,401 Tuberculosis ,603 7,060 Neurological disorders ,016 6,566 12,153 Diseases of kidney and urinary system ,368 15,649 11,383 Cardiovascular diseases ,785 10,326 12,628 Other chronic ailment ,645 16,898 8,158 Other diagnosed ailment ,087 11,298 6,597 Other undiagnosed ailment ,890 4,759 Total ,153 10,036 7, Figure 2: Distribution of Inpatients by Survivor Status, Broad Age Groups and Type of Diseases in India ( ) Relative distribution of diseases Others Chronic Acute Decedents Survivors Decedents Survivors Decedents Survivors Less than 15 years years 60 years and above mean medical expenses for decedents are Rs 6,571 as compared to Rs 3,651 of survivors while the corresponding figures are Rs 13,550 and Rs 8,916 respectively for inpatients treated in private facilities. The OOP expenditure towards physician fee, medicine costs and other medical items for inpatients hospitalised in private facilities is invariably higher than utilisation of public facilities for inpatient care. But the gap between private and public health facilities utilisation for inpatient care for each component of medical expenses for the decedents are much wider than those of survivors. The mean physician fees for decedents treated in private facilities is Rs 4,416 as compared to Rs 714 for those treated in public facilities and for the survivors the mean expenses are Rs 1,123 and Rs 2,249 respectively for the corresponding health facilities. The mean medical costs of decedents who died in private hospital facilities are Rs 6,872 as against It indicates that decedents were admitted to hospital for diseases of a more serious nature than that of the survivors. The OOP expenditure for inpatient care disaggregated by the major purpose of expenditure under medical and nonmedical categories can reveal differentials in charges for physician, costs of medicines, payment for clinical tests, transport and lodging expenses. The public health system in India is unable to keep pace with the demand for healthcare (Singh and Ladusingh 2010) and functions under the public-private partnership strategy. However there is no standardisation of fees and charges for services, facilities, medicines and appliances. As a consequence both outpatient and inpatient care Rs 2,681 for those treated in public facilities. As for the survivors the mean medical costs of inpatients treated in private and public facilities are Rs 2,606 and Rs 1,835 respectively. There is no doubt that the facilities, amenities and appliances used in the private health facilities are better than those used in the public facilities. The exorbitant medical expenses for seeking treatment in private facilities partly include the charges for these amenities. It is a known fact that the economically better-off patients and those who were willing to pay availed healthcare from private facilities. The high medical cost of decedents treated as inpatients in private facilities may be due to physicians expenses in the private health facilities are Table 2: Mean Annual Inpatient Care Expenditure of Decedents and Survivors by Heads of Expenditure and Public-Private Status of Hospitals in India ( ) exorbitant. Table 2 shows the mean annual Heads of Inpatient Care Expenditure Mean Expenditure (in Rs) OOP expenditure for inpatient care for medical Public Hospital Private Hospital All Inpatients and non-medical purposes disaggrega- Decedents Survivors Decedents Survivors Decedents Survivors ted by public and private health facilities for Doctor/surgeon fees 714 1,123 4,416 2,249 3,610 2,094 Medicine 2,681 1,835 6,872 2,606 4,407 2,266 decedents and survivors. Both medical and Other medical expenditure ,098 1,948 2,013 1,629 non-medical expenses of decedents are much Other charges , , higher than that of survivors regardless of Expenditure not reported elsewhere 6,117 2,556 9,921 6,768 8,182 5,314 the public or private status of the hospital. Total medical expenditure 6,571 3,651 13,550 8,916 10,134 6,885 The OOP expenditure for care of inpatients Transport , treated in private health facilites is much Lodging charges , , higher than that of those treated in public Other non-medical expenditure facilities, both for decedents and survivors. Total non-medical expenditure , For inpatients treated in public facilities the Total inpatient expenditure 6,212 3,829 14,151 9,319 10,036 7,126 march 16, 2013 vol xlviii no 11 EPW Economic & Political Weekly

4 prescribing more expensive life-saving drugs and subjecting patients to advanced treatments. The share of non-medical expenses in the total OOP expenditure for inpatient care is within 8-12% irrespective of the survival status of inpatients and public-private affiliation of the health facilities. Table 3: Distribution and Mean Annual Inpatient Care Expenditure by Survival Status and Background Characteristics of Inpatients in India ( ) Background Decedents Survivors Characteristics Percent/ N Mean Inpatient Percent/ N Mean Inpatient Mean Expenditure Mean Expenditure (in Rs) (in Rs) Age (in years) Less than , ,753 3, , ,866 7, and above , ,534 8,514 Sex Male , ,475 7,495 Female , ,678 6,717 Place of residence Rural , ,643 6,144 Urban , ,510 9,294 MPCE tertile Poor , ,613 4,563 Middle , ,604 6,150 Rich , ,936 10,946 Hospital type Public , ,249 3,829 Private , ,904 9,319 Disease groups Acute , ,223 4,828 Chronic , ,687 9,389 Others , ,243 6,567 Hospitalisation days ,153 - Total ,036 31,153 7,126 The OOP expenditure for hospitalised care for decedents and survivors not only varies by ailments but also by demographic and economic background of the inpatients as can be seen from Table 3. The distribution of decedents and survivors varies by age, for survivors there are more inpatients in the years age group and lesser in the 60 plus group while for decedents a sizeable proportion of them are in 60 plus group. There are more male and rural residents for both decedents and survivors but no distributional differential by monthly per capita consumption expenditure (MPCE) tertile, a proxy for economic well-being. Among the decedents nearly an equal proportion of inpatients utilised the public and private health facilities while three-fifths of the survivors utilised the private facilities. A higher proportion of decedents utilised inpatient care for chronic diseases as compared to the survivors. The mean number of days of hospitalisation of decedents is higher by two days than that of the survivors. It has been noted in the preceding discussion on results that the mean cost of inpatient care is higher for the treatment of chronic diseases and for the hospitalisation in private health facilities. It is noted that for decedents the mean OOP expenditure for inpatients in all the three broad age groups is more than the expenditure of survivors in the corresponding age groups. For male and rural decedents the mean cost of the OOP inpatient care is nearly twice the OOP expenditure on inpatient SPECIAL ARTICLE care of the survivors of the same sex and residence background. The mean OOP expenditure for the inpatient care of the survivors shows a significant difference by MPCE tertiles both for decedents and survivors. The mean OOP expenditure for rich inpatients is more than twice the expenditure of poor inpatients irrespective of the survival status. The four versions of the two-level random intercept model described in the methodology section are implemented to assess the fit of the proposed model and make out which of the demographic and economic correlates have a significant effect on OOP expenditure. Model I is an empty model with no covariate control but with a random intercept, which is found to be significant at p<0.01. The significance of random intercept indicates considerable variation in mean OOP expenditure for inpatient care between individuals and between episodes of hospitalisation of individuals. The random effect parts of the twolevel model points out considerable variation in OOP expenditure between individuals and also between episodes of individuals and these are statistically significant at p<0.01. In Model II residence, economic well-being measured by MPCE tertile and the survival status of individuals are included, in addition to random intercept. Even after controlling for residence, economic and the survival status of inpatients, the OOP expenditure varies significantly between individuals and between episodes of hospitalisation and are still statistically significant at p<0.01. The OOP expenditure for inpatient care for survivors is significantly less than that for the decedents after Economic & Political Weekly EPW march 16, 2013 vol xlviii no 11 47

5 SPECIAL ARTICLE Table 4: Main Effects of Selected Variables on Cost of Inpatient Care in India ( ) Fixed Effects Model I Model II Model III Model IV Constant Place of residence Rural Urban MPCE tertile MPCE 1 MPCE MPCE Survival status Decedents Survivors Sex Male Female Age (in years) Less than 15 years years More than 59 years Type of health facility Public Private Disease groups Chronic Acute Other diseases Duration of hospitalisation (in days) Random effects u e Deviance 1,15,021 1,13,896 1,05,160 1,04,467 Intraclass correlation coefficient : Reference category, MPCE: monthly per capita consumption expenditure. controlling for residence and the MPCE tertile and so is that of urban residents in comparison to that of rural residents after adjusting for economic and survival status (Table 4). The rural-urban difference is largely because of the urban residents who enjoy better provision and accessibility of facility for inpatient care and adoption of preventive care from worsening health conditions. The significantly higher OOP expenditure for inpatient care of decedents even after adjusting for residence and economic status confirms the high expenses for decedents regardless of the background of the inpatients. When the confounding effect of residence and economic status are adjusted compared to inpatients from the lowest MPCE tertile, those from the middle and the highest MPCE tertile incurred higher OOP expenditure. This finding is statistically significant at p<0.01 and supports the absolute income hypothesis that the economically better off spend more on healthcare. Model III is designed to examine differential in OOP expenditure for inpatient care by age, sex, public-private affiliation of the health facility, types of disease and duration of hospitalisation controlling for survival status of inpatients. The inpatient care OOP expenditure for females is less than that for their male counterparts when the other effects of other correlates just mentioned are adjusted and the difference is statistically significant. This is a reflection of discriminatory social practices in intra-household resource allocation. It is also evident that inpatient care cost tends to increase according to the advancing age of inpatients as expenditure of 48 inpatients in the and 60 plus years age group is significantly higher than that of younger inpatients under 15 years of age. The result supports the hypothesis of high healthcare cost at the end of life. OOP expenditure for inpatients treated in private health facilities is higher than that of inpatients in public health facilities and the longer the duration of hospitalisation the higher is the cost of inpatient care. Inpatient care for acute and other diseases is less expensive than that of treatment for chronic diseases. These differences by age, duration of hospitalisation and affiliation of health facilities are all significant at p<0.01. Model V examines the contribution of demographic, economic and survival status, type of disease, duration of hospitalisation and public-private status of health facilities in explaining variation in OOP expenditure for inpatient care. From the χ2 test of deviance statistics of the successive aforesaid models, it comes out that Model IV provides the best fit. Even after controlling all the aforesaid correlates, there is still significant difference in the mean OOP expenditure for inpatient care between individuals and between episodes of hospitalisation, but the size of difference has reduced as compared to the empty model and the other two models where the effects of correlates were partially controlled. In the final model the direction and levels of statistical significance of individual correlate when the rest are controlled remain unchanged but the magnitudes of their main effects have reduced marginally. This indicates the importance of age, sex, residence background, economic and survival status, types of diseases, duration of hospitalisation and public-private affiliation of the health facilities in explaining the variation in OOP expenditure of inpatient care in India. Conclusions This study examined the relationship between decedents and survivors OOP expenditure for inpatient care, which includes both medical and non-medical expenses. The findings that the cost of inpatient care of decedents is much higher than that of the survivors, particularly for those residing in rural areas, staying longer in hospitals, utilising private health facilities and suffering from chronic diseases are important for future healthcare system development and resource planning. The knowledge of the high decedent-to-survivor inpatient care costs ratio can be combined with increasing life expectancy and prevalence of morbidity to access the healthcare needs of the gradually ageing population of India. Lower inpatient care OOP expenditure for urban residents is indicative of the need for the expansion of the public healthcare system in rural areas. Higher inpatient care expenditure by richer patients also indicates the high utilisation of health facilities by the affluent leaving the poor out of the healthcare net. There is significant differential in the OOP inpatient care cost between individuals and between episodes of hospitalisation of individuals. The intra-class correlation coefficient of hospitalisation episodes expenditure of individuals is as high as 0.30, which indicates that subsequent inpatient care OOP expenditure remains high. There is no evidence of such a study in India and the geriatric healthcare programme can take note of the high inpatient care cost at the end of life for especially embarked social security and other social assistance. march 16, 2013 vol xlviii no 11 EPW Economic & Political Weekly

6 References Emanuel, E, D L Fairelough, J Slutsman and L Emanuel (2000): Understanding Economic and Other Burdens of Terminal Illness: The Expenditure of Parents and Their Caregivers, Annals Internal Medicine, 132: Garg, C C and A K Karan (2009): Reducing Out-of- Pocket Expenditure to Reduce Rural Poverty: A Disaggregated Analysis at Rural-Urban Level in India, Health Policy Planning, 24 (2): Ginzberg, E (1980): The High Cost of Drying, Inquiry, 17: Hogan, C, J Lunney, J Gabel and J Lynn (2001): Medicare Beneficiaries Costs of Care in the Last Year of Life, Health Affairs, 20(4): Ladusingh, L and A Pandey (2013): Health Expenditure and Impoverishment in India, Journal Health Management (forthcoming). 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Zweifel, P, Felder S Werblow A (2004): Population Aging and Health Care Expenditure: New Evidence on the Red Herring, Health Economics, 8(6): Appendix The list of diseases in chronic, acute and others groups and items of expenditure included in other medical expenditure and charges for this study are provided below: Chronic Diseases The chronic diseases considered in this study includes gastritis/gastric/peptic ulcer, disorders of joints and bones, tuberculosis, neurological disorders, disease of kidney and urinary system, cardiovascular diseases (includes hyper tension, diabetes mellitus, heart disease) SPECIAL ARTICLE and other chronic diseases (includes amoebiosis, gynaecological disorders, sexually transmitted diseases, jaundice, filariasis, cancer and other tumours, anaemia, goitre, undernutrition, psychiatric disorders, cataract, disease of mouth, teeth and gum, prostrate disorders, locomotor disability, visual disability, speech disability and hearing disability). Acute Diseases The acute illnesses considered in this study are fever of unknown origin, diarrhoea/ dysentery, bronchial asthma, respiratory including ear/nose/throat, accidents/injuries/ burns/fractures/poisoning and other acute diseases (includes diseases of mouth/teeth and gums, disease of skin, whooping cough, malaria, conjunctivitis, tetanus, mumps, eruptive, diphtheria). Other Diseases The others category of diseases includes other diagnosed and undiagnosed ailments. Other Expenditures Other medical expenditure includes diagnostic charges, bed charges, attendant charges, physiotherapy, and personal medical appliances. Other charges under medical expenditure include expenditure on food and other materials, blood, oxygen cylinder, etc, services (ambulance, etc). 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