Death at no cost? Persons with no health insurance claims in the last year of life in Switzerland

This study used routinely collected Swiss HIC data in a retrospective, secondary analysis of data that are described in detail elsewhere [12]. To summarize, data from six of the 10 largest insurers operating in the Swiss market were pooled and used to track healthcare use over the last year of life of adults who died between 2008 and 2010 [13]. The insurance providers delivered data on sex, date of birth, date of death, place of residence (community or postcode), and complete records of HIC of policyholders. Based on the communities in which they resided, we deterministically linked data on level of urbanization, language region, and neighbourhood socioeconomic status.

Using dates of birth and death, sex, and place of residence, we probabilistically linked the insured persons file to the death certificates in the Swiss Federal Statistical Office’s database (see [12] for details on linkage procedure and results). In addition to causes of death, this data linkage also provided information about civil status and nationality.

Basic health insurance, which covers all services related to illness and pregnancy deemed medically necessary and cost-appropriate, is mandatory for and offered to all Swiss residents with no prior checks or restrictions [14]. Eighty-one private insurers (at the time closest to the end of the study period, 10 August 2011) offered the mandatory basic insurance package. Insurers vary greatly in size and coverage from the 858,005 insured by CSS (which provided data for this study) to 170 persons insured by Krankenkasse Zeneggen [13]. The mean number of those insured by all providers is 96,045 (standard deviation 167,746).

Residents choose a deductible in a range of 300–2500 Swiss Francs (1 CHF = 0.85 Euro = 1.01 US$, as of 25 December 2017); higher deductibles and managed care plans lower the cost of premiums. Social assistance subsidizes premiums for low-income persons. Hospital claims are delivered directly to insurers, whereas a majority of other services is paid by individuals and later reimbursed by insurers after deductibles have been met. Individuals can voluntarily supplement the basic insurance package with private insurance to add further provider and treatment choices (e.g., complementary medicine, dental care) and cover additional benefits (e.g., a private room during a hospital stay). A separate mandatory insurance system covers HIC that are accident related [4, 7, 8, 12, 15].

We hypothesized that having no health insurance claims in the last year of life may occur in two main ways: either a person used no healthcare, or healthcare was delivered but no HIC were filed (Fig. 1). In the first case, a person could have died having had no need of healthcare, having had all healthcare needs met by the family, having refused treatment, having been incapable of finding or paying for healthcare, having been undertreated, or a person could have died suddenly with no possibility of medical care. In the second case, care was in fact delivered but for one reason or another information on its cost never reached the insurer. This could happen, for example, in situations in which healthcare was paid entirely out-of-pocket or by supplemental healthcare insurance, the cost of care did not reach the level of the relevant deductible and information about that cost did not reach the insurer, or a patient or caregiver was not willing or capable of handling the HIC documents.

Guided by previous work [12], we stratified analyses by sex. In the last year of life, the absence of reimbursed HIC as opposed to having some HIC was a binary outcome of the analyses. We calculated frequencies of persons with and without HIC and proportions of persons without HIC across covariates. We used logistic regression with robust standard errors that adjusted for clustering of decedents within regions of residence [16]. Multivariable models included age in 5-year bands, nationality (Swiss or foreigner, including unknown), and civil status (single, married, widowed, divorced), and cause of death, which was coded according to the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10): cardiovascular diseases (CVD, all I codes), cancer (all C codes), mental and behavioural disorders (all F codes), diseases of the nervous system (all G codes), respiratory diseases (all J codes), diseases of the digestive system (all K codes) accidents and assaults (all V, all W and X00-X59, X85-X99, Y00-Y09, Y85-Y86 codes), suicide (X60-X84 codes), and other (remaining codes). Characteristics of regions of residence included level of urbanization (urban, periurban, rural), language region (German, French, Italian) and quintiles of median area-based socioeconomic position (Swiss-SEP) index [17]. We conducted supplementary analyses by main causes of death to explore whether the associations differed across these strata. These analyses further aggregated age categories in order to have a sufficient number of events across groups.

We found demographic, health, and socioeconomic differentials in the lack of health insurance claims, and possibly costs, in the last year of life. Several groups of patients identified by sex, age, civil status, and cause of death had a higher probability of not having HIC. Region of residence had little effect, and associations with age and civil status varied for certain causes of death.

This is the first study to the authors’ knowledge to have looked at the lack of mandatory health insurance (MHI) reimbursed healthcare in the last year of life. We used a large, diverse, and representative database of HIC augmented by probabilistic linkage to a database of causes of death and regional characteristics [12]. MHI covers the entire range of providers, including hospital and ambulatory care, medication, and nursing home medical costs.

Unsurprisingly, patterns identified in this study reflect other findings on overall cost of care [12]. For example, persons who died of cancer had higher costs and lower probability of having had no HIC whereas for younger, widowed, and divorced persons the opposite was true. Men and unmarried persons in the U.S. were also found less likely to receive care in the last year of life [18]. Being male, younger, healthier, and living alone was also found to be associated with higher failure to pay insurance premiums in Switzerland [19], and could partly support our findings of either delayed healthcare or lack of healthcare needs in groups with these attributes. Reich et al. showed that persons of lower socioeconomic status, who receive social assistance, generally have higher intensity and cost of healthcare [20], which parallels our weak association of no HIC among individuals from high Swiss-SEP regions. Similarly as in the case of mortality, the use of ecological instead of individual SEP may be a reason for weaker association [17]. The Reich et al. study also identified higher rates of social assistance among those suffering from psychological disorders and psychoses (identified using pharmaceutical cost groups) [20], which supports the idea that these groups might be more economically vulnerable. Mental illness has been associated with problems in paying medical bills [21] and forgone medical and prescription care [22], and these findings parallel results of this study. Finally, a review of international data (excluding Switzerland) estimated that around 23% of persons had no contact with primary care in the last year of life, with lower figures for women than men and for older than younger persons [23]. Our estimates indicate lower proportions, potentially suggesting higher use of healthcare; however, we included any MHI claim, which might lead to an overestimate.

Our results suggest that persons with mental and behavioural disorders, those who are prone to suicide, and persons who are unmarried might be more likely to be unable to identify health needs, fail to seek needed healthcare, or to some degree be less able to handle healthcare-related administrative tasks. Married persons, in contrast, might be more likely to have their HIC submitted after death by a spouse. Future research should therefore explore why healthcare is not utilized by particular groups. Researchers and policy makers also should be aware that analyses based only on persons having HIC might have a differential bias that misses certain groups; studies of healthcare costs might choose to log-transform the outcomes and exclude persons with zero cost [24]. Although the lack of cost seems to be rare phenomenon in EOL studies, other aspects of healthcare use might be more affected.

As is also true of other HIC-based studies, this analysis had limited access to individual-level characteristics that could potentially explain observed patterns. For instance, morbidity, functional status, patient preferences, chosen deductibles, and individual socioeconomic position are not available in HIC data yet could influence lack of HIC and should be explored. An estimated 2–3% of all claim invoices are paid by patients directly and never reach their insurers [7]. This could potentially have had an impact on our results, particularly among persons with high deductibles or those dying from causes of death not associated with frequent or expensive healthcare use. Switzerland has a relatively high share of out-of-pocket payments in the last year of life [10], and persons with high deductibles are known to incur lower costs [25]. Though the last year of life is used frequently [9], it is still an arbitrary time frame [26]. Our previous analyses indicate that it performs similarly to the last 3 months of life when analysing costs [12].