Patients With Multiple Chronic Diseases Incur High Out-of-Pocket Expenses Interview with:

Dr Grace Sum Chi-En National University of Singapore

Dr Grace Sum    Chi-En

Dr Grace Sum Chi-En
National University of Singapore What is the background for this study?

Response: Chronic diseases are conditions that are not infectious and are usually long-term, such as diabetes, hypertension, cancer, chronic lung disease, asthma, arthritis, stroke, obesity, and depression. They are also known as non-communicable diseases (NCDs). Multimorbidity, is a term we use in our field, to mean the presence of two or more NCDs. Multimorbidity is a costly and complex challenge for health systems globally. With the ageing population, more people in the world will suffer from multiple chronic diseases.

Patients with multimorbidity tend to need many medicines, and this incurs high levels of out-of-pocket expenditures, simply known as cost not covered by insurance. Even the United Nations and World Health organisation are recognising NCDs as being an important issue.

Governments will meet in New York for the United Nations 3rd high-level meeting on chronic diseases in 2018. Global leaders need to work towards reducing the burden of having multiple chronic conditions and providing financial protection to those suffering multimorbidity.

Our research aimed to conduct a high-quality systematic review on multimorbidity and out-of-pocket expenditure on medicines. What are the main findings? 

Response: We found an association between multimorbidity in patients and out-of-pocket spending on medicines. As the number of chronic diseases increased from none to one, we found that the annual out-of-pocket expenditure grew by an average of 2.7 times. An increase from one to two conditions and from two to three increased average costs by 5.2 and 10.1 times, respectively.

The increasing costs also meant that patients could afford fewer other medical services.

Even with the same number of non-communicable diseases, certain specific combinations of chronic conditions yielded higher out-of-pocket spending on medicines.

The elderly was more vulnerable to higher OOPE on medicines, while some evidence suggested medicine out-of-pocket spending accounted for a greater proportion of income for low-income groups

Our research also found a common coping mechanism by some patients with high spending on medicines is non-adherence, whereby patients stop taking their medicines by failing to refill their prescriptions. What should readers take away from your report?

 Response: There are many messages from our study.

Patients may have financial support from insurance benefits to visit their general practitioners or go for medical check-ups, but the weakest link is the lack of financial support to pay for any medications prescribed. The nature of chronic diseases is that they require long-term management and usually cannot be cured, which exacerbates the high cost to patients for medicines over a long period of time. It is imperative for healthcare policymakers to start recognising this problem, in order to design better policies that offer financial protection on medicines for chronic diseases.

It is challenging for patients to navigate fragmented health systems. And due to the high out-of-pocket costs, some stop taking their medicines. This translates into them not managing their multiple conditions, resulting in higher medical costs in the long-run when they get sicker.

Policymakers should move from a single-disease framework to one that takes into account multimorbidity, when allocating funds and when designing policies aimed at financial protection. Targeted government funding and support programmes should take into account multimorbidity status of individuals, particularly for the elderly and low-income groups who are most vulnerable to out-of-pocket spending hardships. Policy measures could include exemptions from certain costs for the elderly and low socioeconomic status groups, lower caps on copayments and subsidies for vital drugs. Prescription drug cost sharing benefit plans must be designed to provide enhanced and broadened coverage for multimorbidities, particularly for certain NCD combinations.

A crucial clinical implication relates to the need for better clinical prescription guidelines to prevent prescription of unnecessary medicines and generic drugs for chronic illness which may cause unwarranted expenditures on medicines by patients. What recommendations do you have for future research as a result of this work?

Response: There are no specific areas of research recommended per se.

However, healthcare policymakers, and global organisations need to develop better financial protection policies so that people do not fall through the gaps in health insurance coverage, which exposes them to high costs from medicines due to multimorbidity.

Policymakers must work towards equitable access to treatment to all populations, especially the marginalised. Our study shows the disparities in out-of-pocket spending which is potentially a barrier to health equity, and arguably, a human rights issue regarding the equitable treatment of chronic diseases. Anything else you wish to share? 

Response: I would like to thank National University of Singapore for their support in my research work. Importantly, I wish to give a special mention to my senior author and mentor, Dr John Tayu Lee from the University of Melbourne, for his valuable contributions. I would also like to express a huge thank you to my other collaborators, Prof Rifat Atun, Prof Chris Millett, A/Prof Gerald Koh, Dr Thomas Hone, Prof Marc Suhrcke, and Prof Ajay Mahal.

To share, I studied veterinary medicine at the University of Melbourne which makes me a veterinarian by-training. My research used to involve using animal models to study many different types of diseases from respiratory conditions like asthma, to neurological issues. Currently, I am a public health researcher in Singapore enjoying the research I do every day!

Any disclosures?

No disclosures. There are no competing interests for this publication. 


Multimorbidity and out-of-pocket expenditure on medicines: a systematic review

Grace Sum, Thomas Hone, Rifat Atun, Christopher Millett, Marc Suhrcke, Ajay Mahal, Gerald Choon-Huat Koh, John Tayu Lee

BMJ Global Health Feb 2018, 3 (1) e000505; DOI: 10.1136/bmjgh-2017-000505

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Last Updated on February 12, 2018 by Marie Benz MD FAAD