Perceived Financial Barriers to Healthcare Worsen Cardiovascular Outcomes Even in Countries With Universal Medical Coverage

PRAGUE, Czech Republic—Cardiovascular disease patients with perceived financial barriers to things like medications and healthy food have worse outcomes than those who don’t, even in a country with universal healthcare, according to a Canadian study.

“The popular view is we have universal healthcare in Canada, so finances aren't a problem. If you ask most Canadians, that's actually what they would tell you. But as clinicians, we know that's often not the case,” David Campbell, MD, MSc, PhD (University of Calgary, Canada), told TCTMD. Campbell presented the study as a poster at the 2017 European Atherosclerosis Society meeting earlier this week. .

Although prior studies have shown links between financial barriers and worse outcomes in the United States, he said, it was not initially clear if the same associations would exist in Canada, where healthcare is primarily paid for by the government. “We don't have pharmaceutical insurance publicly available to everybody,” Campbell explained. “So lots of people fall through the cracks there.”

For their study, the researchers analyzed data between 2000 and 2011 from the Canadian Community Health Survey and the Canadian Mortality Database of 120,752 patients (≥ 45 years old) with self-reported hypertension, diabetes, stroke, or CAD. Survey respondents were asked about perceived financial barriers to home care, medications, healthcare providers/tests, healthy food, health behavior modifications, or other unmet needs.

After adjustment, 10.2% of individuals surveyed reported at least one financial barrier, with access to medications and healthy food being the most commonly cited obstacles. Those reporting at least one barrier had a 36% higher rate of being hospitalized and a 24% higher rate of cardiovascular death than those with no perceived barriers. Inpatient costs were also Can $ 364 higher in those with at least one perceived financial barrier.

All barriers were independently associated with higher rates of disease-related hospitalization, with the exception of health behavior modification. Campbell acknowledged that the survey may have lacked the proper statistical power to tie individual barriers to outcomes as “the same questions were not asked of all participants in all years,” but financial barriers to health behavior modifications are “much further upstream” than limited access to medications, he commented. “If somebody faces financial barriers to weight loss, well, there are a lot of other things that might affect their cardiovascular outcomes.”

Campbell said his group is currently working with policymakers in Alberta to help them know where to focus intervention efforts. “This data certainly doesn't say which intervention should be targeted to address these barriers, but what it does say is that financial barriers are a problem in Canada and it's not something we can ignore,” he observed, adding that his team’s main suggestions for increased governmental attention are access to medication and healthy food.

The next step will be a large intervention study “looking at the impact of providing co-payment-free medication insurance to Albertans at high risk of heart disease,” Campbell said.

International Lessons

Acknowledging the differences between the Canadian healthcare system and that of his home country of Brazil, Sergio Kaiser, MD, MSc, PhD (Rio de Janeiro State University, Brazil), said his government—which provides public access to healthcare that more affluent citizens supplement with private insurance—and those of other emerging countries could learn from this study. “The most important lesson is to focus on prevention,” he told TCTMD.

“Of course the health system in Canada is much more developed than in an emerging country like Brazil. Even if it’s universal, the money has to come from somewhere,” Kaiser said. “This is not surprising because in people who have financial barriers, of course this will have an impact. The conclusion is logical.”

In Brazil specifically, “we have to consider the quality of the healthcare, the mobility of urban centers, [and] the lack of doctors in some smaller urban centers,” he commented. While past efforts of the Brazilian government to ban smoking have been successful, Kaiser added, there is much more work to be done with regards to lowering the intake of sugar and salt by the country’s citizens. “We can save money with prevention,” he reaffirmed.