“In our study, around 1 in 10 patients (10.7%) were affected by out-of-pocket health-care expenses and had seen one of their household members forgo health care during the 12 previous months. GPs could help diminish the health burden caused by existing disparities if only they could identify these patients more easily.[24] This study reveals a simple way to help GPs screen for and rule out the risk of forgoing health care for economic reasons: ask patients whether their household has had difficulties paying its bills. Asking directly if a patient has forgone health care for economic reasons may lead to an important underestimation because of social desirability bias and stigma. The patient might fear that his GP will not care for him if he cannot afford to pay.[25], [26] Furthermore our study shows that this single question performed better than a combination of information from objective socio-economic-status markers. Interestingly, physicians’ attitudes and beliefs concerning their role in caring for deprived patients may also have an impact on whether patients forgo health care.

“Even in a universal and compulsory private health insurance coverage system with subsidies for individuals on low incomes, the prevalence of patients forgoing health care was high, similar to the results of a national telephone survey[10] but slightly lower than the prevalence reported in Geneva’s urban-population-based surveys.[9], [11] International comparisons are difficult because of the multitude of factors related to national health systems, but a recent American study did show that 10% of US families did not obtain the care they needed due to the financial burden such care entailed.[19] Thus, one can see that cost-sharing health policies generate health disparities in similar proportions in other countries.[22]

“Identifying patients facing financial difficulties and economic hardship is an important challenge for GPs who generally do not assess patients for problems related to out-of-pocket health-care costs[24], [27], [28]: previously noted obstacles to such an assessment are not feeling at ease discussing financial issues, insufficient time, and a lack of solutions for a problem perceived as unsolvable. Yet while, in a study by Alexander et al,[24] patients (305/484, 63%) and physicians (105/133, 79%) believed that discussion of out-of-pocket costs was important, these discussions only occurred infrequently (35% for physicians and 15% for patients). In our study, it was seen that using a simple screening question can reasonably rule out the risk of forgoing health care for economic reasons. This single question is easy to use because it is less stigmatizing than asking about actual income. It is also not country-specific and performs better than a combination of information from objective and individual social-economic predictors (NPV 96%). That said, asking patients directly about the financial consequences of health-care expenses might be more relevant. This is especially the case when planning expensive investigations or treatments. Asking about difficulties paying bills is probably more relevant if we are interested in knowing if a patient is at risk of forgoing health care due to difficulties that they have not yet been confronted with. If patients are positive for this single screening question, this screen would encourage patients and physicians to engage in a more in-depth discussion about out-of-pocket costs, individualized plans of treatment depending on patient circumstances, and the consequences of forgoing health care for economic reasons.”

Bodenmann, P., Favrat, B., Wolff, H., Guessous, I., Panese, F., Herzig, L., Bischoff, T., Casillas, A., Golano, T., & Vaucher, P. (2014). Screening primary-care patients forgoing health care for economic reasons. PloS one, 9(4), e94006. doi.org/10.1371/journal.pone.0094006.

“For patients consulting their GP in western Switzerland, period prevalence of forgoing health care during the previous 12 months was 10.7% (95%CI, 9.4–12.1). Compared to other patients, those whose household members had forgone health care due to out-of-pocket expenses had a lower household-income, were younger, were more likely to suffer from poverty, were more likely to receive income from social- or unemployment welfare, a study grant, or a wage, but were less likely to be from a household with sources of income from retirement, private assets, or a widow’s pension, or to have Swiss nationality (Table 1). Forgoing health care was associated with each of the 16 items used in the deprivation index DIPCare-Q,[16] the material index, subjective social status evaluated by patients or physicians, and health status (Table 2). However, not having access to the Internet was only associated with forgoing health care for patients older than 65. Physicians’ self-perceived role was also associated with patient risk of forgoing health care. Adjusting for other factors, forgoing health care was less likely for patients who were seen by physicians who perceived that their role was to care for deprived patients (OR_adj = 0.68; CI95% 0.47 to 0.97), or by physicians who stated that they forgo additional investigation or expensive treatments when appropriate (OR_adj = 0.52; CI95% 0.33 to 0.81). On the other hand, physicians who stated that they feel powerless when facing patient deprivation were more likely to have patients forgo health care (OR_adj = 1.5; CI95% 1.1 to 2.1). These three factors were accounted for when measuring the magnitude of each question about forgoing health care (Table 3, Model 2).”

Bodenmann, P., Favrat, B., Wolff, H., Guessous, I., Panese, F., Herzig, L., Bischoff, T., Casillas, A., Golano, T., & Vaucher, P. (2014). Screening primary-care patients forgoing health care for economic reasons. PloS one, 9(4), e94006. doi.org/10.1371/journal.pone.0094006.

Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and several other nations.

Page last updated May 20, 2021 by Doug McVay, Editor.