DSpace at VNU: Economic vulnerability of methadone maintenance patients: Implications for policies on co-payment services

DSpace at VNU: Economic vulnerability of methadone maintenance patients: Implications for policies on co-payment service...

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Title: Economic vulnerability of methadone maintenance

patients: Implications for policies on co-payment services

Author: Bach Xuan Tran Huong Thu Thi Phan Long Hoang

Nguyen Cuong Tat Nguyen Anh Tuan Le Nguyen Tuan Nhan

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Economic vulnerability of methadone maintenance patients:

implications for policies on co-payment services

Bach Xuan Tran1,2*, Huong Thu Thi Phan3, Long Hoang Nguyen1,4, Cuong Tat Nguyen5

, Anh Tuan Le Nguyen5, Tuan Nhan Le6, Carl A Latkin2

Lecturer in Health Economics

Hanoi Medical University, Vietnam

Assistant Professor (Adjunct)

Bloomberg School of Public Health

Johns Hopkins University, USA

bach@hmu.edu.vn | bach@jhu.edu

+84-982228662

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Abstract

Background: Co-payment for methadone maintenance treatment (MMT) services is a strategy

to ensure the financial sustainability of the HIV/AIDS programs in Vietnam In this study, we

examined health services utilization and expenditure among MMT patients, and further explored

factors associated with catastrophic health expenditure among affected households

Methods: A multi-site cross-sectional study was conducted among 1,016 patients in two

epicentres: Hanoi and Nam Dinh province in 2013

Results: Overall, 8.2% and 28.7% respondents used inpatient and outpatient health care

services in the past 12 months apart from receiving MMT There were 12.8% respondents

experiencing catastrophic health expenditure given MMT is provided free-of-charge, otherwise

63.5% patients would suffer from health care costs MMT integrated with general health or HIV

services may encourage health care services utilization of patients Patients, who were single,

lived in the rural, had inpatient care and reported problems in Mobility were more likely to

experience catastrophic health expenditure than other patient groups

Conclusions: The health care costs are still financially burden to many drug users and

remained over the course of MMT that implies the necessity of continuous supports from the

program Scaling-up and decentralizing integrated MMT clinics together with economic

empowerments for treated drug users and their families should be prioritized in Vietnam

Keywords: methadone, integrative services, health services, costs, catastrophic, Vietnam

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Introduction

People who inject drugs (PWIDs) are a key population at increased risk of HIV are considered a

major driver of the explosion of HIV in Asia countries1 Recent data estimates that 4.5 million of

PWIDs out of 13 million drug users (DUs) live in this region The financial burden of drug

addiction involves not only the costs for this risk behavior but also huge costs for health care

services and loss of productivity2-5 Murphy and Scott defined the “economic vulnerability as the

exposure of a household to exogenous shocks related to the wider glboal economic crisis and

subsequent adoption of austerity policies and the potential for diminishing life satisfaction and

quality of life”6 In this study, we focused on the burden of health care costs that affected PWIDs

and their households In developing countries such as Vietnam, drug users may spend much

higher than average household monthly income, which results in economic burden on

households4 In addition, it has also been a barrier for those who acquired HIV to access and

use health care services7 Illicit drug use is known to reduce significantly adherence to and

outcomes of antiretrovial treatment Therefore, opioid substitution treatment for DUs plays an

indispensable role in international HIV/AIDS prevention strategies

Currently, methadone maintenance treatment (MMT) has been used as an effective therapy for

people dependent on opioids8-12 In Vietnam, patients have been receiving MMT free-of-charge,

however, since international fundings for HIV/AIDS is decreasing rapidly, resource mobilization

using co-payment is considered2,11,13 Finding from prior reviews demonstrated that MMT

minimized the demands of opioid use; crime activities, HIV-related risk behaviors and diseases,

as well as promoted HIV/AIDS care services access and improved quality of life14-18 Among

drug users living with HIV, MMT also helped reduce healthcare services use and out-of-pocket

(OOP) health expenditure19 Thus, implementing and scaling-up MMT program has been

considered a cost-effective intervention in both developed and developing countries11-13,20-23 The

Vietnam Ministry of Health set a target for providing MMT services for 80,000 drug users by

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2015 During the period of this study, some provinces, for instance, Hai Phong, there were few

MMT sites applied the co-payment schemes that patients pay for averagely US$0.5 per day For

other health care services, there was no subsidy and patients or their health insurers are

supposed to pay their OOPs money for the services4

The public health system in Vietnam is organised into three levels: central, provincial and

grassroots25 Primary medical care services are provided throughout the country, however, high

reliance on out-of-pocket financing for health exposes households to potential catastrophic

expenditures and creates inequality in access to care 26 Current estimates showed OOP

payments accounted for 30-70% total health expenditure in various settings 4,27-30 The percentage

of public expenditure in health in the total health spending in Vietnam was estimated to be 40%31 Model to

deliver MMT services varies across settings such as stand-alone or integrating with other health

care services13 When freestanding model emphasizes the role of confidential services,

combination programs facilitate the variety of health service utilized by drug users3,20 The

linkage of MMT service and general health care services were mentioned in the late 1980s,

since previous reports suggested the high prevalence of co-morbidities, low frequency of health

care use and daily clinic visit to uptake MMT among DUs 32 By combining different components

of health care service into a single site; or providing referral between them, these models give a

chance to address the unmet needs of DU for medical services10,13 The effectiveness of linked

services have been well documented, including promote health care utilization, improve health

outcome and treatment adherence 10,13,19 This model also reduces the health care cost of

communities as well as the duplication of services and their administration cost 33, therefore, it

may improve the efficiency of the service delivery system However, the performance of different

integrative models in diverse settings as well as patients’ responses has not been examined In

Vietnam, there has been evidence that services quality and socio-cultural and economic factors,

rather than geographical barriers, may affect the use of health services in both general and

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related populations Thus, comparing across models for MMT delivery can provide insights

for improving the efficiency of the MMT program

HIV epidemic in Vietnam is recognized in a concentrated stage, which is primarily driven by

unsafe sex with comercial sex workers and illicit drug injection3,38 It is estimated that about

180,000 people are using illicit drug in the country by 2012, of those, 20-50% were contracted

HIV/AIDS39 The MMT program has been prioritized in the National HIV/AIDS Strategy and

rapidly scaled up nationwide at a daily cost of US$1 per patient 2,20 Recent data reported an

approximate of 15,500 DUs enrolling for treatment, with 26,8% were PWIDs2 Vietnam Ministry

of Health targeted covering 80,000 DUs on the program in 2015 The impact of MMT on health

services utilization and OOP payments in Vietnam are mentioned in the previous investigation

analysis, however, the sample included only those living with HIV/AIDS19 To date, none of the

literature analysed health services utilization and expenditure of drug users over the course of

MMT or examined the role of different service delivery models on these outcomes of interest

This study assessed health service use and OOP health spending of MMT patients in MMT

clinics with and without other general health or HIV/AIDS services; and further explored factors

associated with catastrophic health expenditure among this patient group

Materials and Methods

Study settings and sampling

A multi-site cross-sectional study was conducted in two Vietnamese epicentres: Hanoi and Nam

Dinh from January to August 201313 The selection of provinces were purposive, in consultation

with the Vietnam Authority of HIV/AIDS Control, that included a setting with new MMT sites

(Nam Dinh) and a setting with other sites since the first national pilot (Ha Noi)3,20

These areas were amongst those with the greatest HIV epidemic in northern Vietnam Five

selected clinics were classified to two delivery models comprised: stand-alone (Provincial AIDS

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Centre – Nam Dinh) and integrated into general healthcare facilities (Xuan Truong district health

center in Nam Dinh provinces; Tu Liem and Long Bien district health centers and Ha Dong

regional polyclinic in Hanoi) At these clinics, patients have been receiving MMT free-of-charge

The selection was based on following criteria: 1) These clinic had been providing MMT services;

2) including provincial-, regional- and district-level clinics and 3) having sufficient patients for the

study In this sample we also considered the involvement of rural and urban sites which located

in the rural district (Xuan Truong) or urban cities (Table 1).The inclusion criteria for participants

were: 1) respondents were 18 years or older; 2) enrolling MMT programs or having requested to

participate the program; 3) agreeing to sign in written informed consents and 4) having capacity

to answer a 30-45 minutes interview All patients met criteria and went to selected clinics during

study period were invited to participate in the study A convenient sample of 1,016 participants

was recruited in the study

Measures and instruments

Data was collected by master students and medical doctors with extensive experience with IDU

and MMT Patients were invited to a confidential room, which was designated for face-to-face

interview Their self-reported information was collected using a structured questionnaires

comprising: socioeconomic status, health status, health-related quality of life household monthly

expenditure, health service utilization and OOP of healthcare expenditure19,36,40 Health related

quality of life was measured using the EuroQol-five dimensions-five level (EQ-5D-5L) which has

been widely used in HIV studies in Vietnam36,40,41 The descriptive system includes five

domains: Mobility, Self-care, Usual activities, Pain/Discomfort and Anxiety/Depression

with five levels of response: no problems, slight problems, moderate problems, severe

problems, and extreme problems, giving 3125 health states with respective single

indexes

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Household monthly expenditure was computed including two components: recurring expenses in

the last 30 days (e.g food, utility, rent, education and others) and non-recurring expenses in the

last 12 months (e.g construction, health care, furniture, travels, community events and others)

To calculate OOP health expenditure per capita, the sum of healthcare expenses was divided to

the total number of family members4,5,42 Catastrophic health expenditure was defined as the

proportion of health care payments over 10% of the total households’ expenditure43-45

Health service utilization of respondents included inpatient and outpatient care in the last 12

months (regular outpatient clinic visits for ARV and MMT medications were excluded) This

measure was frequently applied in prior national surveys2,4,36,46-50 Cost per inpatient and

outpatient visit were estimated by recalling the expenditure of patients in the last use of health

services Interviewers guided patients to list all services and procedures of the last health care,

and associated cost items Patients then estimated the costs by activity while the interviewers

triangulated them with the total costs Unit costs comprised two elements: 1) medical

expenditure (non-ARV and –MMT drugs, lab tests, hospital fees and other) and 2) non-medical

spending (transportations, accommodation and special meals if any) Total OOP payments for

healthcare services of MMT patients were estimated by multiplying the frequency of healthcare

service utilization by the average costs per visit

Statistical analysis

Data was analysed using STATA version 12.0 To examine the difference of those

characteristics between delivery models, Student t-test and Chi-squared test were used

Household monthly income, expenditure, the rate of healthcare services utilization and costs per

inpatient and outpatient visits were presented in both means (95% CI) Multiple logistic

regression was used to determine correlates of experiencing catastrophic OOP health

expenditure and havingany inpatient or outpatient health service use in the past year Multiple

linear regression was used to determine correlates of OOP health expenditure (unit: 1000

Vietnam dong) We applied a stepwise forward model building strategy that selected variables

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based on the log-likelihood ratio test at a P-value <0.1 Statistical significance was set at

p-value<0.05

Ethical approval

The research was approved by the Scientific Committee of the Authority of HIV/AIDS Control,

Ministry of Health, Vietnam The purposes of study were clearly introduced to all respondents

before obtaining their written informed consents Participants could refuse to participate in the

study or withdraw at any time without any disadvantages in utilizing health services Since MMT

is provided free-of-charge, participants did not receive remuneration for answering the

questionnaire The response rate was 80-90%

Their personal information was ensured to be confidential by using special codes and both paper

questionnaires were secured

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Results

Of 1,016 respondents, mean age was 36.8 (SD=7.6) years and 1.28% patients were female

About two-thirds (67.5%) were living with spouse or partners; 44.7% completed high school or

above, and 53.4% were self-employed Overall, in the past 12 months, 8.2% and 28.7%

respondents used inpatient and outpatient health care services, respectively, apart from having

MMT This health service use rate was significantly higher in outpatient care use among

respondents in the rural compared to other groups Among those having used inpatient and

outpatient health services, 70% and 80% were fully capable to pay for the associated cost,

respectively There were 12.8% respondents experiencing catastrophic health expenditure,

although MMT is free-of-charge In the scenario that patients pay fully for MMT, it was estimated

that there will be 63.5% patients suffering from health care costs (Table 2)

The unit cost for an inpatient and outpatient health service used by MMT patients are presented

in table 3 By different services models, we found that those patients attending integrated MMT

services at urban DHC reported the highest number of days for hospitalization and sick leave In

both types of services, non-medical costs and medical unit costs were significantly lower among

MMT patients at a rural health facility than urban ones In table 4, we found that medication was

the major driver of health care costs, accounting for 43% - 59% of the total direct medical costs

Patients mainly paid out-of-pocket for their total health care costs (86% - 95%), meanwhile, only

9% inpatient- and 4% outpatient- care costs were covered by health insurers

Over the past year, OOP health expenditure by patients in the rural was the highest among all

patient groups (Table 5) Since direct medical costs by patients at rural DHC was comparable to

other integrative and comprehensive HIV services, rural patients should have had higher

non-medical costs than other patients groups We found that patients who attending MMT without

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general health care and HIV services reported fewer hospitalization days as well as spent less

for inpatient and outpatient care services The total household expenditure per capita was lower

in the rural clinics

Factors associated with health care service utilization and OOP health expenditure were

presented in Table 6 Higher level of education attainment, employment, self-reported health

problem and having health services use significantly associated with higher health expenditure

Patients, who were single, lived in the rural, had inpatient care and reported problems in Mobility

were more likely to experience catastrophic health expenditure than other patient groups

Noticably, patients who reported any Self-Care problem had significantly lower OOP for health

care but no differences in health services use Patients used drug for a longer period were also

more likely to experience catastrophic health expenditure Patients who were attending MMT

clinics with comprehensive general health and HIV services or were having health problems

were more likely to use other out-patient care services While, inpatient-care use was predicted

by younger age, having problems in Pain/ Discomfort and HIV positivity

Discussion

This study analysed health services utilization and assessed the burden of expenditure on health

care by MMT patients It examined economic vulnerability over the course of MMT among

patients who had a history of drug use and emphasizes the importance of maintaining financial

supports for those taking MMT services Comparing across several services delivery models,

findings of this study support the integration of MMT with District Health Centres where general

health care and HIV-related services are offered This type of comprehensive services model is

necessary to improve access to and utilization and outcomes of health care for drug users

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Previous studies have analysed financial burden of health care among patients with HIV/AIDS in

Vietnam, and showed higher OOP expenditure among drug users than others4,5 This study also

found a high expenditure on health care among MMT patients Similarly to previous work, about

two-thirds of drug users taking MMT are likely to suffer from catastrophic health expenditure if

the service is not subsidized4,5 Although MMT services have been widely scaled up in

injection-driven HIV epidemics, mostly in resource-scare settings, few studies have provided empirical

evidence on its impacts on health care costs and economic vulnerability of MMT patients Hsiao

et al showed a reduction in costs of drug addiction over MMT by reduced heroin use and

increased productivity among Taiwanese patients22 Tran et al studied Vietnamese patients

with HIV/AIDS and determined that MMT contributes to a substantial reduction in health care

cost and service utilization by drug users, compared to non-MMT group2,10,19,20 Findings of this

study confirmed that other health care remains a burden financially for drug users independent

of MMT Especially, for those with Self-Care problems, they might not be able to access to

health services nor afforable to pay more for health care Noticeably, the duration on MMT was

excluded in the regression models suggesting that economic vulnerability of this group did not

change significantly over the course of MMT It confirms the need of social supports, vocational

training, and job referrals to improve the social and economic well-being of MMT patients 3,20

This is the first study comparing health service utilization and expenditure of drug users across

different model for MMT service delivery The findings have important implications for scaling up

MMT services in Vietnam First, integrative services model that co-locating MMT with other

general health and HIV services may encourage drug users to access and use other type of

health services This has also been found to be more cost-effective for treating drug users with

HIV/AIDS in Vietnam10,12 Second, financial supports for MMT services are still necessary to

reduce financial hardship due to health care costs among patients and their households

Although co-payment by users for MMT services is critical for the sustainability of the program in

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the rapid decrease of international supports; there was only 41% of drug users taking MMT and

antiretroviral therapy were willing to pay for the full cost of MMT2 Similarly, findings of this study

shows that about two thirds of patients will suffer from catastrophic health expenditure should the

program is no longer subsidized Therefore, the co-payment scheme for MMT services should

be continued and those patients with severe health status, HIV-positive, and living in the rural

should still receive MMT free-of-charge Third, the coverage of health insurance for health care

among this patient group is rather low Recent policy on social health insurance in Vietnam is

encouraging households to buy family package which reduces the fee from the 2nd users The

family involved in social health insurance not only facilitate better health services access,

compliance and outcomes, but also reduce the risk of financial catastrophe due to health care

costs among affected households Therefore, MMT patients and their families should enrol in

social health insurance programs; improving communication and access to health insurers

should also be offered

This study has some advantages included the enrolment of numerous MMT patients and the

involvements of various areas and levels of health care system in two Vietnamese epicentres

However, several drawbacks should be recognized First, the cross-sectional study may limit the

possibility to establish causal relations between delivery models and health care expenditures of

patients A longitudinal study is required to find the causal association of delivery models and

economic burden for health care Second, the generalization of findings for whole population

may be restricted by the sampling technique Third, information obtained was primarily based on

recalls of patients, which may result in under- or over-estimate the household expenditure and

health care cost A study in the rural of Vietnam showed that estimates of catastrophic health

spending may be overestimated51 This might be related to firstly the short recall periods as

usually used in such studies and secondly the inclusion of health expenditure prior to the recall

periods by respondents51.Finally, some factors such as adherence and outcomes of MMT were