Out-of-pocket expenditure and mortality in the elderly in Europe: a longitudinal analysis, 2006-20

BACKGROUND: European Health Systems are increasingly considering the implementation of cost-sharing policies to compensate cuts in public health spending. However, out-of-pocket expenditure (OOPE) has been associated with delay in seeking care, especially in the elderly population, with negative effects on health. This is the first study to assess the relationship between OOPE and mortality in European Health Systems. METHODS: Longitudinal analysis of 11 European Health Systems between 2006 and 2020 using data from the Survey of Health, Ageing, and Retirement in Europe. Total OOPE, OOPE on medicine, outpatient, and inpatient were the main variables of interest. Covariates included multimorbidity, age, sex, marital status, residential country, educational attainment, and household income. To model the association between OOPE and mortality we employed mixed-effect parametric survival models with Gompertz distribution. Analyses were stratified by income quintiles and sensitivity analyses were conducted with time-varying independent variables. RESULTS: Study population included 70367 respondents, average age was 65 year (±14.1), 53.7% were female, and average number of chronic disease was 1.6 (±2.6). 60.1% of the sample paid OOPE, 41.2% more than 100 euros in a year. For each 100 euro increase in OOPE we found a 1% increase in mortality over the study period (HR 1.01, 95%CI 1.01-1.01), with little difference when stratifying analyses by income quintiles. The largest effect was found for OOPE on medicine (HR 1.04, 95%CI 1.02-1.06), while the smallest for OOPE on inpatient (HR 1.02, 95%CI 1.01-1.03), although it was much larger when restricting analyses to only those in the lowest income quintile (HR 1.08, 95% 1.92-1.12). Time-varying analyses confirmed main findings. CONCLUSIONS: Cost-sharing policies, especially on medicine, increase the risk of mortality in elderly people in Europe. For certain health services the association might affect especially the most disadvantaged groups. KEY MESSAGES: • For each 100 euro increase in OOPE we found a 1% increase in mortality for elderly people in Europe over the study period, with little difference when stratifying analyses by income quintiles. • The largest effect was found for OOPE on medicine, while the smallest for OOPE on inpatient, although it was much larger when restricting analyses to only those in the lowest income quintile.