Patients’ attitudes toward copayments as a steering tool—results from a qualitative study in Norway and Germany

Patients’ attitudes toward copayments as a steering tool—results from a qualitative study in... Abstract Background Copayments are implemented in many health care systems. The effect of copayments differs between countries. Up to now, patients’ attitudes regarding copayments are mainly unknown. Objectives Thus, the goal of our analysis was to explore adult patients’ attitudes in Germany and Norway towards copayments as a steering tool. Methods We conducted a qualitative comparative study. Episodic interviews were conducted with 40 patients in Germany and Norway. The interviews were analysed by thematic coding in the framework of grounded theory. All text segments related to copayments were analysed in depth for emerging topics and types. Results We found three dimensions of patients’ attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. The perceived steering effect consists of three types: having been influenced by copayments, not having experienced any influence and the experience of other persons to be influenced. The category comprehensibility describes that not all patients understand rules and regulations of copayments and its caps. The assessment of copayments consists of nine subcategories, three of which are rather negative and six of which are rather positive. In all three dimensions the patterns between the German and Norwegian sub-samples differ considerably. Conclusions The results of our study point at the importance of communicating clear rules for copayments which are easily comprehensible. Comprehensibility, copayments, Germany, Norway, patients’ perspective, qualitative research Background Copayments are an important feature in many health care systems (1). They serve two main functions, first, as a steering tool and, second, as a source of funding. There are three types of copayments: deductibles, copayments in their narrower sense and maximum coverage plans. In this article, we focus on copayments in their narrower sense, also called out-of-pocket-payments. They are a share of the actual costs for seeing a doctor or of pharmaceuticals which the patient has to pay. These out-of-pocket-payments are common in many countries no matter which health care type they belong to (1). There are two concepts underlying the assumed steering effect of copayments. The first idea is that copayments are an instrument to raise the cost-awareness of patients. The second idea is that they make health care services less like a flat rate service (2). This, in turn, assumes, that patients are capable to discern ‘useful’ from ‘superfluous’ services and that copayments stop them from falling for moral hazards (3). Moral hazard means the temptation to use services to a greater extent than one usually would for what has already been paid for, for example by an insurance premium or taxes. However, evidence tends to show copayments are more likely to have a blunt effect because patients are not capable to distinguish between necessary and unnecessary services (4). Best-known evidence for the steering effect of copayments is the ‘Health Insurance Experiment’ conducted by the RAND Corporation in the late 1970s and early 1980s. The experiment showed a clear relation between copayments and utilization, however, it has a several shortcomings. Next to ethical issues no consideration was paid to the cultural, temporal, and methodological implications of the study (5). This makes it difficult to draw valid conclusions for outside the USA. For Belgium and France, studies showed no relevant effect of copayments on health care utilization (6,7). However, poorer groups in society or chronically ill with a higher need of utilizing services tend to refrain from or even delay necessary visits to the doctor because of copayments (8–11). A measure to reduce these unintended, negative health and social effects are caps to copayments. The differing effects of copayments in the different studies have not yet been sufficiently explained. Skriabikova et al. (12) suggest that ‘consumer attitudes, experience and culture’ play a role in the effects of copayments, however, measures of these factors are usually not included in the according studies. O’Reilly et al. (13) conducted a survey regarding patients’ attitudes towards copayments for GP services in Ireland. They see a need for more research on the underlying motives for support for or opposition to copayments. Benedetti et al. (14) found limited knowledge of patients regarding copayments in a US study. One of the few qualitative studies was conducted by Doran et al. (15) who researched Australian patients’ attitudes towards copayments for medication. They found costs not to play a fundamental role. An Irish study researched patients’ attitudes towards a 50 cent copayment for medication (16): patients’ attitudes were somehow accepting but sceptical. Another study conducted by Schafheutle et al. (17) shows that patients follow several strategies to reduce their medication cost. In summary, it can be stated that regarding the widespread use of copayments there is little research on a more comprehensive perspective of patients regarding copayments. Especially, we could not find any qualitative study including patients from more than one health care system. There are several comparative studies from an economical health care system perspective, however, they do not include the patients’ perspective (18–20). Thus, there is a need for more knowledge on the patients’ attitudes towards copayments. Knowledge on patients’ attitudes might allow to explain the differences in effects of copayments. Copayments in Norway and Germany We chose to compare Norway and Germany, because they are similar regarding social structure, morbidity and mortality. Norway has a tax-based health care system while Germany has a social insurance system of the Bismarck type. However, general practitioners (GPs) are working mainly self-employed in both countries. The gross national income per capita is higher in Norway than in Germany [in 2011: 88430$ versus 47360$ (21)] mainly due to oil production. The Gini-Index as a parameter for inequity is in Norway slightly lower than in Germany [in 2011: 25.5 versus 30.1 (22)]. Norway and Germany differ greatly in the use of health services as well as regarding the amount and type of copayments. In both countries, there are or were copayments for visiting the doctor and for medication, but the approaches differ. Germany had opted for a quarterly lump-sum service charge of 10 euros (Praxisgebühr, lit. ‘practice charge’) for each adult patient for any number of consultations and referrals within the particular quarter (23). This practice charge did not prove to have an effect on health care utilization in the mid- and long-term (24). Hence, the practice charge was abolished in 2013. In contrast, out-of-pocket payments in Norway are, as a general rule, paid for every new consultation or service by every adult patient. Fees are graduated according to the kind and daytime of service and the qualification of the provider. Copayments for medication in Germany are in general 10% of the price with a minimum of 5 euros and a maximum of 10 euros per package. There are several additional rules, partly depending on individual contracts of public health insurances with specific pharmaceutical companies. In Norway, there is a distinction between medication for serious and chronic diseases and other medications. The public social insurance pays a larger or major part for medications for serious and chronic diseases. The patient just has to pay a copayment. Other medication usually has to be paid in full by the patient. Copayments for medications for chronic diseases have a cap. There is no such limit for other medications. Patients with low income or suffering from certain illnesses get a taxation reduction in case of high expenditure on nonaddictive medications. Norway has introduced caps for copayments in the early 1980s, Germany followed in 2004 (23,25). Germany limits private expenditures for all kinds of copayments on all reimbursable services, pharmaceuticals, and appliances to 2% of the gross household income (1% for chronically ill) per year (23). Norway, in contrast, applies two separate caps independent of the actual income: one for seeing doctors, psychologists, treatment in hospitals, doing X-rays, copayments for pharmaceuticals and patient transport (cap EUR 240), while the other cap limits copayments for physiotherapy, treatment by dentists, or treatment abroad [cap EUR 210; (26–28)]. In both countries, copayments are a relevant source of funding: in 2012, 12% of the expenditure on health in Germany was paid by private out-of-pocket payments and 15% of the expenditure on health in Norway (29). However, this figure includes more than just copayments and incorporates all privately paid health expenditures. Hence, the research question of this article reads: what are adult patients’ attitudes in Germany and Norway towards copayments as a steering tool? And, do these attitudes differ systematically between these two countries? Methods We conducted a comparative qualitative study in the methodological framework of grounded theory (30). In the study, there were three methodological approaches: qualitative interviews with 40 patients, participant observation in overall eight primary care practices—both equally divided between Germany and Norway—and a context analysis of health care system factors emerging during the analysis. Results from the concurrent participant observation in overall eight primary care practices were not entered in the analysis for this article. Field access was gained via eight primary care practices, four in Norway, four in Germany. In both countries, two practices were situated in a rural setting and two in an urban setting. On at least 2 days, all patients in these practices received a short questionnaire, informing them about the study and asking them to participate in a qualitative interview. Furthermore, these potential interviewees were asked for their age, gender, number of chronic conditions and number of visits to the doctor over the last 3 months. From this pool of 280 potential interviewees, we chose the Norwegian interviewees by theoretical sampling and matched the German interviewees. There were 40 participants, 20 in Germany and 20 in Norway born between 1931 and 1990. Eighteen of the participants were female and 22 male. Twenty-two of the interviewees went to a GP in an urban setting and 18 in a rural setting. The interviews conducted were episodic interviews. Episodic interviews are semi-structured qualitative interviews containing a narrative part relating to the interviewee’s experiences and abstract questions. The interviews were conducted in the years 2012 till 2014. Selected interviews were coded line-by-line to develop an initial thematic structure. Then, we coded all interviews and refined the codes and thematic structure. For a further analysis regarding the attitudes towards copayments as a steering tool, we chose all segments coded with ‘copayments’, ‘financing’, ‘costs’, or ‘self-pay’. These text-segments were analysed further for dimensions of attitudes towards copayments and recurring themes and categories as well as types. All participants gave their written informed consent to participate in the study. The study was approved by the local ethics committees in Germany and Norway. A more detailed description of the study design is available in the study protocol (31). All quotes in this article are followed by the study-ID of the interviewee, including a D for patients from the German sample and N for patients from the Norwegian sample. I denotes the interviewer and P the interviewee. Results We found three dimensions regarding attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. Perceived steering effect of copayments The dimension ‘Perceived Steering Effect of Copayments’ describes how the interviewees perceive the actual steering effect of copayments. We could find three types of interviewees regarding this aspect. The first type are respondents who perceived that copayments had a steering effect on themselves. They reported to have postponed consultations with a doctor for financial reasons. Typical is the following quote of a 40-year-old woman: It was annoying, because I postponed particular diseases, most often those which appeared at the end of the quarter year. Then I said to myself, let’s wait. Let’s wait, because otherwise, you’ve to pay twice. That’s how it is. (D06) To understand the interviewee’s explanation, it is important to know that the copayment for a visit to the physician in outpatient care had to be paid only once in each quarter in Germany. Another type of interview partner were those stating that they themselves had not been influenced, but knew others who were. This type can be summarized by the following quote: We can still afford that [, the copayments], but many others are not able. Then, there was this thing with the ten euros [practice charge]. Many people didn’t see the doctor because they didn’t have these ten euros. And people say, this girl here [in the neighbourhood] died because she did not have these ten euros. If she had gone to see the doctor, she would still be alive. (D03) A third type consists of those who neither see any influence on themselves nor report any influence on people they know of. A typical example is the following: Money doesn’t play a role. And it’s also so convenient, it’s so little money [we have to pay], that has never played a role for me. (N11) However, it is important to notice that whereas interviewees stated that copayments did not influence them personally they mention that copayments might influence peoples’ behaviour in general. For example people stated sometimes that Germans visit the doctor so often because no copayment is necessary. These statements highlight that they assume a general steering effect of copayments on health care utilization. Table 1 shows the distribution of the three types in the qualitative sample. While the Norwegian interviewees experienced nearly uniformly no steering effect of copayments, the types were more equally distributed in the German sample. Table 1. Distribution of three types of perceived steering effect of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (n = 40) Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  NA, not applicable. View Large Table 1. Distribution of three types of perceived steering effect of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (n = 40) Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  NA, not applicable. View Large Comprehensibility of copayments In the German sample of the interviewees, for some participants the rules regarding copayments appeared not to be comprehensible: That’s when you say, they are not quite right in the head: For [medications produced by] one manufacturer I need to pay co-payments, for those by another manufacturer I do not need to pay. And I cannot comprehend all this. (D14) However, not only the rules for in which cases copayments have to be paid but also the rules how to get a remission from copayments once you have exceeded the maximum amount seem to be difficult to understand. One example is the following patient who thinks to be eligible for such a waiver and tried to get one: P: However, I have to pay copayments for the medications I get prescribed. I do not have a remission. We wanted to get one, but they didn’t do it. I always have to pay five euros or seven euros or so. I: So, you don’t have a remission? So, you do not exceed the maximum? P: Oh, I always have to pay. I’ve broached that. Wouldn’t it be better, if I do not have to pay for it with the minimal pension I get? However, I always have to pay for it. And there was this almoner here, and I addressed this topic. But she didn’t do anything. […] Well, but I always have to pay copayments. I haven’t got a waiver yet. […] I broached that topic several times. I said it, but nothing has changed. (D18) This interviewee seems not to know who is responsible to waive the copayments, which requirements have to be fulfilled, and what he has to do in order to get such a waiver. This can be highlighted also by an interviewee who has experience with health care services in both Germany and Norway: P1: And how many copayments I’ve paid, that’s registered at the Norwegian social insurance office. And as soon as I’ve reached the limit, I get the waiver, and everything I’ve paid too much gets re-transferred to my bank account. P2: I do not need to care. P1: And I do not need to care about it my own. I do not need to think about it. I do not have to collect receipts as I had to in Germany. (N13) Accordingly, while in the German sub-sample some interviewees report problems in the comprehensibility of the rules, the Norwegian interviewees did not mention such difficulties. Assessment of copayments Regarding the general assessment of copayments, we could find nine topics. Three with a negative tendency towards copayments: disgrace, commerce and burden. These rather negative assessment types can be contrasted to six with a more positive tendency: the importance of the cap, the perception of copayments as undramatic and fair, health care services as privilege, the educational effect of copayments and health as worth it. A rather negative assessment of copayments The most negative assessment of copayments is the view some German interviewees took. They dispraised copayments as a cruel disgrace: This form of financing the healthcare system is a disgrace. (D14) They highlight that they perceive copayments as inhuman, as in general not acceptable in a social welfare state. This relates to another group of interviewees who regard copayments as being indicative for a negative commerce orientation of the health care system: If they [the healthcare insurances] impel it like the pharmacies do; that’s all just commerce, nothing else. (D19) Thus, interviewees arguing in these two categories regard an economical perspective on health care as generally not acceptable. Hence, the third negative category is more strongly related to the individual perspective. Interviewees of this category highlight that copayments can be a burden for individuals: Well, the financial burden for some of these things is enormous. (D02) Thus, negative assessments of copayments can be more generalized opposing a financial dimension of health care in general or more devoted to the impact of the individual burden of copayments. A more positive assessment of copayments In contrast to these negative stances, several more positive aspects of copayments are mentioned by other interviewees. Instead of perceiving copayments as a burden, some interviewees highlight that the amount of copayments is not dramatic: They [copayments] are nothing dramatic at all. (D11) Some even see it as just a small amount to pay: That is not really a price to pay if you go to such a public doctor. (N20) Connected to assessing the financial burden of copayments as negligible is the role of the cap of copayments. Thus, some of the interviewees highlight the importance of the limit of copayments for their assessment: Costs with visiting the doctor? No, I think that in particular that little bit is absolutely all right. You shall stand for this copayment, and then you get the healthcare exemption card. (N17) The cap is perceived as an important factor to assess copayments and is considered as fair: I: That means you assess these 200, 250 [euros of copayments] as … P: Yes, as fair. (D16) Some interviewees, in particular those, who experienced having a severe disease resulting in high treatment costs highlighted that it is a privilege to get health care paid and how grateful they are. And beyond this gratefulness they assess copayments as a minor amount of money. Other interviewees highlight that health is worth paying what needs to be paid: If health is at stake and I need to see the doctor, then money doesn’t play a role. (N13) Finally, several interviewees highlight that copayments fulfil an educational goal and steer on an abstract level: Well, that’s at least something the state has achieved: Because [of copayments] people didn’t see the doctor so often anymore. (D06) Thus, the positive views of copayments are mainly related to assessing the burden by copayments as small or at least acceptable. This is either due to the relatively small amount of the single copayments or the relatively small overall amount of copayments because of the cap. Table 2 shows the distribution of the different categories in assessing copayments in the qualitative sample. It shows that the assessment of copayments is different between the German and the Norwegian sub-sample. In the German sub-sample, all categories are mentioned, especially also the more negative ones. In the Norwegian sub-sample, the negative categories have not been mentioned and the limit of copayments it is described as undramatic. Table 2. Frequency of mentioned categories regarding the assessment of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (participants can count multiple times, n = 40) Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  NA, not applicable. View Large Table 2. Frequency of mentioned categories regarding the assessment of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (participants can count multiple times, n = 40) Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  NA, not applicable. View Large Discussion In this study, we researched patients’ attitudes towards copayments as a steering tool in Norway and Germany. We found three dimensions of patients’ attitudes towards copayments as a steering tool: the perceived steering effect, the comprehensibility and the general assessment of copayments. A limitation of our study is that there might be a selection bias: because we recruited participants from patients in health care centres, only persons who were willing and able to pay copayments were included in the pool of potential participants. However, for the German sub-sample we could show that there is only a small difference of those interested in taking part in such an interview and the general population. This potential selection bias should be addressed in quantitative follow-up studies by including the socio-economic status of the participants. Another limitation is that copayments for visiting a physician in outpatient care have been abolished in Germany during the course of our study. However, the interviewees still vividly remembered the times of the copayments. The aspect of the comprehensibility of copayment regulations is rarely discussed in literature: Benedetti et al. (14) showed for respondents from a private insurance in the US health care system that 4.4% of the respondents did not know correctly if they had to pay copayments for a consultation and only half of the respondents knew the amount of copayments they had to pay correctly. This is in line with the findings of Hsu et al. (32), who found in another US survey that only half of the respondents knew the amount of their copayments correctly. In a focus group with elderly in the USA, Cline et al. (33) found the aspect of drug benefit comprehensibility which is similar to our dimension of comprehensibility: the regulations were often not comprehensible to the elder patients taking part in Cline’s study. In our qualitative study, there seems to be a difference in comprehensibility between Norway and Germany, comprehensibility being no issue in Norway and a problem for some patients in Germany. This difference in the perceived comprehensibility of copayments might relate to the different rules in the two countries: in Norway, all payments are registered automatically in a central register so that the waiver is sent automatically to the patient in question once the individual copayments have exceeded the fixed amount. In Germany, in contrast, patients need to collect receipts from physician, pharmacies, hospitals, etc. to apply for a waiver to their sickness fund once the amount relative to their income is exceeded. Therefore, patients in Germany need to have organizational skills. This might be inappropriate especially for the ill, disabled, less educated and vulnerable patients and might explain the difference in reported comprehensibility. The divergent assessment of copayments in our study fits to the findings of Sinnott et al. (16) who found diverging assessment of a 50 cent copayment on drugs. They found varying perceptions of copayments from a relevant burden to nothing dramatic. The different patterns of distribution in both samples of our study point towards a different view of copayments in Norway and Germany. In Norway, the function as a financing instrument of copayments seems to dominate. The participants usually saw copayments as a normal part of using the health care system and did mainly not attribute any individual influences on their behaviour. This might be connected to the long existence of copayments in Norway, and their origin in the rather small amount that was initially covered by the health care system. In Germany, patients found the role of copayments less clear, and there was a relevant opposition against copayments. This more critical view is in line with the findings of a survey conducted by Wendt et al. (34) who found an opposition in the German population against higher payments or less service. The different assessment of copayments might be also have been influenced by the different way of paying for the health care system. Paying for health care indirectly through taxes might not as much lead to the feeling of being entitled to a full-scale coverage as paying an individual health care insurance fee. Additionally, our results reveal that an important factor to perceive copayments as fair is a cap for copayments. That this cap is perceived less important for fairness in Germany than in Norway should be further explored. Possible reasons in Germany are that the height of the cap depends on the individual disease status and the individual income and that patients have to collect their receipts actively and apply for a remission reaching the cap. This is contrasted by the Norwegian system with a high degree of automatism. In Norway, the administration and not the patient have to know the rules. Thus, the procedures for copayment caps might influence their perception implicitly. Conclusions Our study highlights that the procedures around and comprehensibility of copayments might be of importance for the perception and understanding of copayments in the population and thereby influence their acceptance. In future, studies on the steering effect of copayments, the individual concepts of copayments should be taken into account. Our results may help to operationalize these concepts for quantitative measurements of such factors. Future studies should explore the interplay of the socio-economic status, health literacy, the perceived steering effect, individual concepts of copayments and the comprehensibility in a quantitative way. The results emphasize that when communicating about copayments one should distinguish the steering function of copayments from the financing function. To relieve patients from the burden to administrate their own copayments, automated caps might be an important measure to increase the acceptance of copayments. Declaration Funding: the study has been funded by the Deutsche Forschungsgemeinschaft (DFG—HE6399/1-1 and HE6399/1–2). Ethics: the study was approved by the local ethics committees in Germany and Norway. Conflict of interest: none. Acknowledgements We thank all researchers and students who contributed to the study, namely Anne-Katharina Koch, Kevin Schröder, Jona Ober, Christina Wagenknecht, Anne Bretschneider, Stephan Bilkenroth, Yvonne Marx, Sigurd Skrondal, Sabina Sendrowicz, Sebastian Huter, Jan Islei, Thomas Lichte, Markus Herrmann and Uwe Flick. Especially, we thank all GPs who allowed us to do participant observation in their practices and all interviewees. References 1. Bíró A. Copayments, gatekeeping, and the utilization of outpatient public and private care at age 50 and above in Europe. Health Policy  2013; 111: 24– 33. Google Scholar CrossRef Search ADS PubMed  2. Drummond M, Towse A. Is it time to reconsider the role of patient co-payments for pharmaceuticals in Europe? 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Strategies for Qualitative Research . Chicago: Aldine, 1967. 31. Herrmann WJ, Haarmann A, Flick Uet al.   Patients’ subjective concepts about primary healthcare utilisation: the study protocol of a qualitative comparative study between Norway and Germany. BMJ Open  2013; 3: e002952. Google Scholar CrossRef Search ADS PubMed  32. Hsu J, Reed M, Brand R, Fireman B, Newhouse JP, Selby JV. Cost-sharing: patient knowledge and effects on seeking emergency department care. Med Care  2004; 42: 290– 6. Google Scholar CrossRef Search ADS PubMed  33. Cline RR, Gupta K, Singh RL, Schommer JC. Older adults’ drug benefit beliefs: a focus group study. J Manag Care Pharm  2005; 11: 77– 85. Google Scholar PubMed  34. Wendt C, Naumann E, Klitzke J. Reformbedarf im deutschen Gesundheitssystem aus Sicht der Bevölkerung. Zeitschrift für Sozialreform  2014; 60: 333– 48. Google Scholar CrossRef Search ADS   © The Author(s) 2017. Published by Oxford University Press. All rights reserved. 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Patients’ attitudes toward copayments as a steering tool—results from a qualitative study in Norway and Germany

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Abstract

Abstract Background Copayments are implemented in many health care systems. The effect of copayments differs between countries. Up to now, patients’ attitudes regarding copayments are mainly unknown. Objectives Thus, the goal of our analysis was to explore adult patients’ attitudes in Germany and Norway towards copayments as a steering tool. Methods We conducted a qualitative comparative study. Episodic interviews were conducted with 40 patients in Germany and Norway. The interviews were analysed by thematic coding in the framework of grounded theory. All text segments related to copayments were analysed in depth for emerging topics and types. Results We found three dimensions of patients’ attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. The perceived steering effect consists of three types: having been influenced by copayments, not having experienced any influence and the experience of other persons to be influenced. The category comprehensibility describes that not all patients understand rules and regulations of copayments and its caps. The assessment of copayments consists of nine subcategories, three of which are rather negative and six of which are rather positive. In all three dimensions the patterns between the German and Norwegian sub-samples differ considerably. Conclusions The results of our study point at the importance of communicating clear rules for copayments which are easily comprehensible. Comprehensibility, copayments, Germany, Norway, patients’ perspective, qualitative research Background Copayments are an important feature in many health care systems (1). They serve two main functions, first, as a steering tool and, second, as a source of funding. There are three types of copayments: deductibles, copayments in their narrower sense and maximum coverage plans. In this article, we focus on copayments in their narrower sense, also called out-of-pocket-payments. They are a share of the actual costs for seeing a doctor or of pharmaceuticals which the patient has to pay. These out-of-pocket-payments are common in many countries no matter which health care type they belong to (1). There are two concepts underlying the assumed steering effect of copayments. The first idea is that copayments are an instrument to raise the cost-awareness of patients. The second idea is that they make health care services less like a flat rate service (2). This, in turn, assumes, that patients are capable to discern ‘useful’ from ‘superfluous’ services and that copayments stop them from falling for moral hazards (3). Moral hazard means the temptation to use services to a greater extent than one usually would for what has already been paid for, for example by an insurance premium or taxes. However, evidence tends to show copayments are more likely to have a blunt effect because patients are not capable to distinguish between necessary and unnecessary services (4). Best-known evidence for the steering effect of copayments is the ‘Health Insurance Experiment’ conducted by the RAND Corporation in the late 1970s and early 1980s. The experiment showed a clear relation between copayments and utilization, however, it has a several shortcomings. Next to ethical issues no consideration was paid to the cultural, temporal, and methodological implications of the study (5). This makes it difficult to draw valid conclusions for outside the USA. For Belgium and France, studies showed no relevant effect of copayments on health care utilization (6,7). However, poorer groups in society or chronically ill with a higher need of utilizing services tend to refrain from or even delay necessary visits to the doctor because of copayments (8–11). A measure to reduce these unintended, negative health and social effects are caps to copayments. The differing effects of copayments in the different studies have not yet been sufficiently explained. Skriabikova et al. (12) suggest that ‘consumer attitudes, experience and culture’ play a role in the effects of copayments, however, measures of these factors are usually not included in the according studies. O’Reilly et al. (13) conducted a survey regarding patients’ attitudes towards copayments for GP services in Ireland. They see a need for more research on the underlying motives for support for or opposition to copayments. Benedetti et al. (14) found limited knowledge of patients regarding copayments in a US study. One of the few qualitative studies was conducted by Doran et al. (15) who researched Australian patients’ attitudes towards copayments for medication. They found costs not to play a fundamental role. An Irish study researched patients’ attitudes towards a 50 cent copayment for medication (16): patients’ attitudes were somehow accepting but sceptical. Another study conducted by Schafheutle et al. (17) shows that patients follow several strategies to reduce their medication cost. In summary, it can be stated that regarding the widespread use of copayments there is little research on a more comprehensive perspective of patients regarding copayments. Especially, we could not find any qualitative study including patients from more than one health care system. There are several comparative studies from an economical health care system perspective, however, they do not include the patients’ perspective (18–20). Thus, there is a need for more knowledge on the patients’ attitudes towards copayments. Knowledge on patients’ attitudes might allow to explain the differences in effects of copayments. Copayments in Norway and Germany We chose to compare Norway and Germany, because they are similar regarding social structure, morbidity and mortality. Norway has a tax-based health care system while Germany has a social insurance system of the Bismarck type. However, general practitioners (GPs) are working mainly self-employed in both countries. The gross national income per capita is higher in Norway than in Germany [in 2011: 88430$ versus 47360$ (21)] mainly due to oil production. The Gini-Index as a parameter for inequity is in Norway slightly lower than in Germany [in 2011: 25.5 versus 30.1 (22)]. Norway and Germany differ greatly in the use of health services as well as regarding the amount and type of copayments. In both countries, there are or were copayments for visiting the doctor and for medication, but the approaches differ. Germany had opted for a quarterly lump-sum service charge of 10 euros (Praxisgebühr, lit. ‘practice charge’) for each adult patient for any number of consultations and referrals within the particular quarter (23). This practice charge did not prove to have an effect on health care utilization in the mid- and long-term (24). Hence, the practice charge was abolished in 2013. In contrast, out-of-pocket payments in Norway are, as a general rule, paid for every new consultation or service by every adult patient. Fees are graduated according to the kind and daytime of service and the qualification of the provider. Copayments for medication in Germany are in general 10% of the price with a minimum of 5 euros and a maximum of 10 euros per package. There are several additional rules, partly depending on individual contracts of public health insurances with specific pharmaceutical companies. In Norway, there is a distinction between medication for serious and chronic diseases and other medications. The public social insurance pays a larger or major part for medications for serious and chronic diseases. The patient just has to pay a copayment. Other medication usually has to be paid in full by the patient. Copayments for medications for chronic diseases have a cap. There is no such limit for other medications. Patients with low income or suffering from certain illnesses get a taxation reduction in case of high expenditure on nonaddictive medications. Norway has introduced caps for copayments in the early 1980s, Germany followed in 2004 (23,25). Germany limits private expenditures for all kinds of copayments on all reimbursable services, pharmaceuticals, and appliances to 2% of the gross household income (1% for chronically ill) per year (23). Norway, in contrast, applies two separate caps independent of the actual income: one for seeing doctors, psychologists, treatment in hospitals, doing X-rays, copayments for pharmaceuticals and patient transport (cap EUR 240), while the other cap limits copayments for physiotherapy, treatment by dentists, or treatment abroad [cap EUR 210; (26–28)]. In both countries, copayments are a relevant source of funding: in 2012, 12% of the expenditure on health in Germany was paid by private out-of-pocket payments and 15% of the expenditure on health in Norway (29). However, this figure includes more than just copayments and incorporates all privately paid health expenditures. Hence, the research question of this article reads: what are adult patients’ attitudes in Germany and Norway towards copayments as a steering tool? And, do these attitudes differ systematically between these two countries? Methods We conducted a comparative qualitative study in the methodological framework of grounded theory (30). In the study, there were three methodological approaches: qualitative interviews with 40 patients, participant observation in overall eight primary care practices—both equally divided between Germany and Norway—and a context analysis of health care system factors emerging during the analysis. Results from the concurrent participant observation in overall eight primary care practices were not entered in the analysis for this article. Field access was gained via eight primary care practices, four in Norway, four in Germany. In both countries, two practices were situated in a rural setting and two in an urban setting. On at least 2 days, all patients in these practices received a short questionnaire, informing them about the study and asking them to participate in a qualitative interview. Furthermore, these potential interviewees were asked for their age, gender, number of chronic conditions and number of visits to the doctor over the last 3 months. From this pool of 280 potential interviewees, we chose the Norwegian interviewees by theoretical sampling and matched the German interviewees. There were 40 participants, 20 in Germany and 20 in Norway born between 1931 and 1990. Eighteen of the participants were female and 22 male. Twenty-two of the interviewees went to a GP in an urban setting and 18 in a rural setting. The interviews conducted were episodic interviews. Episodic interviews are semi-structured qualitative interviews containing a narrative part relating to the interviewee’s experiences and abstract questions. The interviews were conducted in the years 2012 till 2014. Selected interviews were coded line-by-line to develop an initial thematic structure. Then, we coded all interviews and refined the codes and thematic structure. For a further analysis regarding the attitudes towards copayments as a steering tool, we chose all segments coded with ‘copayments’, ‘financing’, ‘costs’, or ‘self-pay’. These text-segments were analysed further for dimensions of attitudes towards copayments and recurring themes and categories as well as types. All participants gave their written informed consent to participate in the study. The study was approved by the local ethics committees in Germany and Norway. A more detailed description of the study design is available in the study protocol (31). All quotes in this article are followed by the study-ID of the interviewee, including a D for patients from the German sample and N for patients from the Norwegian sample. I denotes the interviewer and P the interviewee. Results We found three dimensions regarding attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. Perceived steering effect of copayments The dimension ‘Perceived Steering Effect of Copayments’ describes how the interviewees perceive the actual steering effect of copayments. We could find three types of interviewees regarding this aspect. The first type are respondents who perceived that copayments had a steering effect on themselves. They reported to have postponed consultations with a doctor for financial reasons. Typical is the following quote of a 40-year-old woman: It was annoying, because I postponed particular diseases, most often those which appeared at the end of the quarter year. Then I said to myself, let’s wait. Let’s wait, because otherwise, you’ve to pay twice. That’s how it is. (D06) To understand the interviewee’s explanation, it is important to know that the copayment for a visit to the physician in outpatient care had to be paid only once in each quarter in Germany. Another type of interview partner were those stating that they themselves had not been influenced, but knew others who were. This type can be summarized by the following quote: We can still afford that [, the copayments], but many others are not able. Then, there was this thing with the ten euros [practice charge]. Many people didn’t see the doctor because they didn’t have these ten euros. And people say, this girl here [in the neighbourhood] died because she did not have these ten euros. If she had gone to see the doctor, she would still be alive. (D03) A third type consists of those who neither see any influence on themselves nor report any influence on people they know of. A typical example is the following: Money doesn’t play a role. And it’s also so convenient, it’s so little money [we have to pay], that has never played a role for me. (N11) However, it is important to notice that whereas interviewees stated that copayments did not influence them personally they mention that copayments might influence peoples’ behaviour in general. For example people stated sometimes that Germans visit the doctor so often because no copayment is necessary. These statements highlight that they assume a general steering effect of copayments on health care utilization. Table 1 shows the distribution of the three types in the qualitative sample. While the Norwegian interviewees experienced nearly uniformly no steering effect of copayments, the types were more equally distributed in the German sample. Table 1. Distribution of three types of perceived steering effect of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (n = 40) Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  NA, not applicable. View Large Table 1. Distribution of three types of perceived steering effect of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (n = 40) Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  Type  Norway  Germany  Influenced me  1  4  Influenced others  1  3  Did not influence  18  12  NA  0  1  NA, not applicable. View Large Comprehensibility of copayments In the German sample of the interviewees, for some participants the rules regarding copayments appeared not to be comprehensible: That’s when you say, they are not quite right in the head: For [medications produced by] one manufacturer I need to pay co-payments, for those by another manufacturer I do not need to pay. And I cannot comprehend all this. (D14) However, not only the rules for in which cases copayments have to be paid but also the rules how to get a remission from copayments once you have exceeded the maximum amount seem to be difficult to understand. One example is the following patient who thinks to be eligible for such a waiver and tried to get one: P: However, I have to pay copayments for the medications I get prescribed. I do not have a remission. We wanted to get one, but they didn’t do it. I always have to pay five euros or seven euros or so. I: So, you don’t have a remission? So, you do not exceed the maximum? P: Oh, I always have to pay. I’ve broached that. Wouldn’t it be better, if I do not have to pay for it with the minimal pension I get? However, I always have to pay for it. And there was this almoner here, and I addressed this topic. But she didn’t do anything. […] Well, but I always have to pay copayments. I haven’t got a waiver yet. […] I broached that topic several times. I said it, but nothing has changed. (D18) This interviewee seems not to know who is responsible to waive the copayments, which requirements have to be fulfilled, and what he has to do in order to get such a waiver. This can be highlighted also by an interviewee who has experience with health care services in both Germany and Norway: P1: And how many copayments I’ve paid, that’s registered at the Norwegian social insurance office. And as soon as I’ve reached the limit, I get the waiver, and everything I’ve paid too much gets re-transferred to my bank account. P2: I do not need to care. P1: And I do not need to care about it my own. I do not need to think about it. I do not have to collect receipts as I had to in Germany. (N13) Accordingly, while in the German sub-sample some interviewees report problems in the comprehensibility of the rules, the Norwegian interviewees did not mention such difficulties. Assessment of copayments Regarding the general assessment of copayments, we could find nine topics. Three with a negative tendency towards copayments: disgrace, commerce and burden. These rather negative assessment types can be contrasted to six with a more positive tendency: the importance of the cap, the perception of copayments as undramatic and fair, health care services as privilege, the educational effect of copayments and health as worth it. A rather negative assessment of copayments The most negative assessment of copayments is the view some German interviewees took. They dispraised copayments as a cruel disgrace: This form of financing the healthcare system is a disgrace. (D14) They highlight that they perceive copayments as inhuman, as in general not acceptable in a social welfare state. This relates to another group of interviewees who regard copayments as being indicative for a negative commerce orientation of the health care system: If they [the healthcare insurances] impel it like the pharmacies do; that’s all just commerce, nothing else. (D19) Thus, interviewees arguing in these two categories regard an economical perspective on health care as generally not acceptable. Hence, the third negative category is more strongly related to the individual perspective. Interviewees of this category highlight that copayments can be a burden for individuals: Well, the financial burden for some of these things is enormous. (D02) Thus, negative assessments of copayments can be more generalized opposing a financial dimension of health care in general or more devoted to the impact of the individual burden of copayments. A more positive assessment of copayments In contrast to these negative stances, several more positive aspects of copayments are mentioned by other interviewees. Instead of perceiving copayments as a burden, some interviewees highlight that the amount of copayments is not dramatic: They [copayments] are nothing dramatic at all. (D11) Some even see it as just a small amount to pay: That is not really a price to pay if you go to such a public doctor. (N20) Connected to assessing the financial burden of copayments as negligible is the role of the cap of copayments. Thus, some of the interviewees highlight the importance of the limit of copayments for their assessment: Costs with visiting the doctor? No, I think that in particular that little bit is absolutely all right. You shall stand for this copayment, and then you get the healthcare exemption card. (N17) The cap is perceived as an important factor to assess copayments and is considered as fair: I: That means you assess these 200, 250 [euros of copayments] as … P: Yes, as fair. (D16) Some interviewees, in particular those, who experienced having a severe disease resulting in high treatment costs highlighted that it is a privilege to get health care paid and how grateful they are. And beyond this gratefulness they assess copayments as a minor amount of money. Other interviewees highlight that health is worth paying what needs to be paid: If health is at stake and I need to see the doctor, then money doesn’t play a role. (N13) Finally, several interviewees highlight that copayments fulfil an educational goal and steer on an abstract level: Well, that’s at least something the state has achieved: Because [of copayments] people didn’t see the doctor so often anymore. (D06) Thus, the positive views of copayments are mainly related to assessing the burden by copayments as small or at least acceptable. This is either due to the relatively small amount of the single copayments or the relatively small overall amount of copayments because of the cap. Table 2 shows the distribution of the different categories in assessing copayments in the qualitative sample. It shows that the assessment of copayments is different between the German and the Norwegian sub-sample. In the German sub-sample, all categories are mentioned, especially also the more negative ones. In the Norwegian sub-sample, the negative categories have not been mentioned and the limit of copayments it is described as undramatic. Table 2. Frequency of mentioned categories regarding the assessment of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (participants can count multiple times, n = 40) Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  NA, not applicable. View Large Table 2. Frequency of mentioned categories regarding the assessment of copayments in the qualitative interview material of 20 German and 20 Norwegian interviewees (participants can count multiple times, n = 40) Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  Category  Norway  Germany  Disgrace  0  2  Burden  0  5  Commerce  0  3  Importance of limit  8  1  Undramatic  10  3  Fair  3  1  Privilege  3  3  Educational effect  3  4  Health is worth it  3  3  NA  5  3  NA, not applicable. View Large Discussion In this study, we researched patients’ attitudes towards copayments as a steering tool in Norway and Germany. We found three dimensions of patients’ attitudes towards copayments as a steering tool: the perceived steering effect, the comprehensibility and the general assessment of copayments. A limitation of our study is that there might be a selection bias: because we recruited participants from patients in health care centres, only persons who were willing and able to pay copayments were included in the pool of potential participants. However, for the German sub-sample we could show that there is only a small difference of those interested in taking part in such an interview and the general population. This potential selection bias should be addressed in quantitative follow-up studies by including the socio-economic status of the participants. Another limitation is that copayments for visiting a physician in outpatient care have been abolished in Germany during the course of our study. However, the interviewees still vividly remembered the times of the copayments. The aspect of the comprehensibility of copayment regulations is rarely discussed in literature: Benedetti et al. (14) showed for respondents from a private insurance in the US health care system that 4.4% of the respondents did not know correctly if they had to pay copayments for a consultation and only half of the respondents knew the amount of copayments they had to pay correctly. This is in line with the findings of Hsu et al. (32), who found in another US survey that only half of the respondents knew the amount of their copayments correctly. In a focus group with elderly in the USA, Cline et al. (33) found the aspect of drug benefit comprehensibility which is similar to our dimension of comprehensibility: the regulations were often not comprehensible to the elder patients taking part in Cline’s study. In our qualitative study, there seems to be a difference in comprehensibility between Norway and Germany, comprehensibility being no issue in Norway and a problem for some patients in Germany. This difference in the perceived comprehensibility of copayments might relate to the different rules in the two countries: in Norway, all payments are registered automatically in a central register so that the waiver is sent automatically to the patient in question once the individual copayments have exceeded the fixed amount. In Germany, in contrast, patients need to collect receipts from physician, pharmacies, hospitals, etc. to apply for a waiver to their sickness fund once the amount relative to their income is exceeded. Therefore, patients in Germany need to have organizational skills. This might be inappropriate especially for the ill, disabled, less educated and vulnerable patients and might explain the difference in reported comprehensibility. The divergent assessment of copayments in our study fits to the findings of Sinnott et al. (16) who found diverging assessment of a 50 cent copayment on drugs. They found varying perceptions of copayments from a relevant burden to nothing dramatic. The different patterns of distribution in both samples of our study point towards a different view of copayments in Norway and Germany. In Norway, the function as a financing instrument of copayments seems to dominate. The participants usually saw copayments as a normal part of using the health care system and did mainly not attribute any individual influences on their behaviour. This might be connected to the long existence of copayments in Norway, and their origin in the rather small amount that was initially covered by the health care system. In Germany, patients found the role of copayments less clear, and there was a relevant opposition against copayments. This more critical view is in line with the findings of a survey conducted by Wendt et al. (34) who found an opposition in the German population against higher payments or less service. The different assessment of copayments might be also have been influenced by the different way of paying for the health care system. Paying for health care indirectly through taxes might not as much lead to the feeling of being entitled to a full-scale coverage as paying an individual health care insurance fee. Additionally, our results reveal that an important factor to perceive copayments as fair is a cap for copayments. That this cap is perceived less important for fairness in Germany than in Norway should be further explored. Possible reasons in Germany are that the height of the cap depends on the individual disease status and the individual income and that patients have to collect their receipts actively and apply for a remission reaching the cap. This is contrasted by the Norwegian system with a high degree of automatism. In Norway, the administration and not the patient have to know the rules. Thus, the procedures for copayment caps might influence their perception implicitly. Conclusions Our study highlights that the procedures around and comprehensibility of copayments might be of importance for the perception and understanding of copayments in the population and thereby influence their acceptance. In future, studies on the steering effect of copayments, the individual concepts of copayments should be taken into account. Our results may help to operationalize these concepts for quantitative measurements of such factors. Future studies should explore the interplay of the socio-economic status, health literacy, the perceived steering effect, individual concepts of copayments and the comprehensibility in a quantitative way. The results emphasize that when communicating about copayments one should distinguish the steering function of copayments from the financing function. To relieve patients from the burden to administrate their own copayments, automated caps might be an important measure to increase the acceptance of copayments. Declaration Funding: the study has been funded by the Deutsche Forschungsgemeinschaft (DFG—HE6399/1-1 and HE6399/1–2). Ethics: the study was approved by the local ethics committees in Germany and Norway. Conflict of interest: none. Acknowledgements We thank all researchers and students who contributed to the study, namely Anne-Katharina Koch, Kevin Schröder, Jona Ober, Christina Wagenknecht, Anne Bretschneider, Stephan Bilkenroth, Yvonne Marx, Sigurd Skrondal, Sabina Sendrowicz, Sebastian Huter, Jan Islei, Thomas Lichte, Markus Herrmann and Uwe Flick. Especially, we thank all GPs who allowed us to do participant observation in their practices and all interviewees. References 1. Bíró A. Copayments, gatekeeping, and the utilization of outpatient public and private care at age 50 and above in Europe. Health Policy  2013; 111: 24– 33. Google Scholar CrossRef Search ADS PubMed  2. Drummond M, Towse A. Is it time to reconsider the role of patient co-payments for pharmaceuticals in Europe? 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For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Family PracticeOxford University Press

Published: Sep 16, 2017

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