Co-payments in health care

Co-payments are health care costs that are payed directly by the patients, either as a fixed fee or a share of the total costs. Changes in co-payments can be used as a means to influence health care utilisation. In 2011, SBU published a systematic review with the purpose to summarize systematic reviews that had investigated how the use of co-payments influence patients’ health and the demand for care.

The governmental inquiry Coordinated development for good quality, local health care (S 2017:01) has asked the SBU Enquiry Service to make an update of systematic reviews that have been published subsequently.


  • What systematic reviews address the impact of co-payments for health care visits on patient health or on the demand for health care visits?
  • What systematic reviews address the impact of co-payments for pharmaceuticals on patient health, or on the demand for pharmaceuticals and other care services?

Identified literature in SBU’s previous review of systematic reviews (before 2011)

Co-payments for health care visits

Skriabikova O, Pavlova M, Groot W. Empirical models of demand for out-patient physician services and their relevance to the assessment of patient payment policies: a critical review of the literature. Int J Environ Res Public Health. 2010;7(6):2708-25.

Co-payments for pharmaceuticals

Austvoll-Dahlgren A, Aaserud M, Vist G, Ramsay C, Oxman AD, Sturm H, et al. Pharmaceutical policies: effects of cap and co-payment on rational drug use. The Cochrane database of systematic reviews. 2008(1):CD007017.

Corrieri S, Heider D, Matschinger H, Lehnert T, Raum E, Konig HH. Income-, education- and gender-related inequalities in out-of-pocket health-care payments for 65+ patients - a systematic review. International journal for equity in health. 2010;9:20.

Gadkari AS, McHorney CA. Medication nonfulfillment rates and reasons: narrative systematic review. Curr Med Res Opin. 2010;26(3):683-705.

Goldman DP, Joyce GF, Zheng Y. Prescription drug cost sharing: associations with medication and medical utilization and spending and health. Jama. 2007;298(1):61-9.

Green CJ, Maclure M, Fortin PM, Ramsay CR, Aaserud M, Bardal S. Pharmaceutical policies: effects of restrictions on reimbursement. The Cochrane database of systematic reviews. 2010(8):CD008654.

Lexchin J, Grootendorst P. Effects of prescription drug user fees on drug and health services use and on health status in vulnerable populations: a systematic review of the evidence. International journal of health services : planning, administration, evaluation. 2004;34(1):101-22.

Page RL, 2nd, Barton P, Nair K. Effect of cost-sharing for prescription medications on health outcomes in older adults: a critical review of the literature and potential implications for managed care. The Consultant pharmacist : the journal of the American Society of Consultant Pharmacists. 2008;23(1):44-54.

Identified systematic reviews by the Enquiry Service (after 2010)

Co-payments for health care visits

Flores-Mateo G, Violan-Fors C, Carrillo-Santisteve P, Peiro S, Argimon JM. Effectiveness of organizational interventions to reduce emergency department utilization: a systematic review. PloS one. 2012;7(5):e35903.

Hone T, Lee JT, Majeed A, Conteh L, Millett C. Does charging different user fees for primary and secondary care affect first-contacts with primary healthcare? A systematic review. Health policy and planning. 2017;32(5):723-31.

Kiil A, Houlberg K. How does copayment for health care services affect demand, health and redistribution? A systematic review of the empirical evidence from 1990 to 2011. The European journal of health economics : HEPAC : health economics in prevention and care. 2014;15(8):813-28.

Rezayatmand R, Pavlova M, Groot W. The impact of out-of-pocket payments on prevention and health-related lifestyle: a systematic literature review. European journal of public health. 2013;23(1):74-9.

Co-payments for pharmaceuticals (general population)

Acosta A, Ciapponi A, Aaserud M, Vietto V, Austvoll-Dahlgren A, Kosters JP, et al. Pharmaceutical policies: effects of reference pricing, other pricing, and purchasing policies. The Cochrane database of systematic reviews. 2014(10):Cd005979.

Babar ZUD, Atif M. Differential pricing of pharmaceuticals: A bibliometric review of the literature. Journal of Pharmaceutical Health Services Research. 2014;5(3):149-56.

Happe LE, Clark D, Holliday E, Young T. A systematic literature review assessing the directional impact of managed care formulary restrictions on medication adherence, clinical outcomes, economic outcomes, and health care resource utilization. Journal of managed care & specialty pharmacy. 2014;20(7):677-84.

Kolasa K, Kowalczyk M. The effects of payments for pharmaceuticals: a systematic literature review. Health economics, policy, and law. 2017:1-18.

Lee IH, Bloor K, Hewitt C, Maynard A. International experience in controlling pharmaceutical expenditure: influencing patients and providers and regulating industry - a systematic review. Journal of health services research & policy. 2015;20(1):52-9.

Luiza VL, Chaves LA, Silva RM, Emmerick IC, Chaves GC, Fonseca de Araujo SC, et al. Pharmaceutical policies: effects of cap and co-payment on rational use of medicines. The Cochrane database of systematic reviews. 2015(5):Cd007017.

Ogbechie OA, Hsu J. Systematic review of benefit designs with differential cost sharing for prescription drugs. The American journal of managed care. 2015;21(5):e338-48.

Viswanathan M, Golin CE, Jones CD, Ashok M, Blalock SJ, Wines RC, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Annals of internal medicine. 2012;157(11):785-95.

Co-payments for pharmaceuticals (patients with chronic diseases or other specific diseases)

Aziz H, Hatah E, Makmor Bakry M, Islahudin F. How payment scheme affects patients' adherence to medications? A systematic review. Patient preference and adherence. 2016;10:837-50.

Bestvina CM, Zullig LL, Yousuf Zafar S. The implications of out-of-pocket cost of cancer treatment in the USA: a critical appraisal of the literature. Future oncology (London, England). 2014;10(14):2189-99.

Davies MJ, Gagliardino JJ, Gray LJ, Khunti K, Mohan V, Hughes R. Real-world factors affecting adherence to insulin therapy in patients with Type 1 or Type 2 diabetes mellitus: a systematic review. Diabetic medicine : a journal of the British Diabetic Association. 2013;30(5):512-24.

Doshi JA, Li P, Ladage VP, Pettit AR, Taylor EA. Impact of cost sharing on specialty drug utilization and outcomes: a review of the evidence and future directions. The American journal of managed care. 2016;22(3):188-97.

Gourzoulidis G, Kourlaba G, Stafylas P, Giamouzis G, Parissis J, Maniadakis N. Association between copayment, medication adherence and outcomes in the management of patients with diabetes and heart failure. Health policy (Amsterdam, Netherlands). 2017;121(4):363-77.

Heidari P, Cross W, Crawford K. Do out-of-pocket costs affect medication adherence in adults with rheumatoid arthritis? A systematic review. Seminars in arthritis and rheumatism. 2018.

Lee JL, Maciejewski M, Raju S, Shrank WH, Choudhry NK. Value-based insurance design: quality improvement but no cost savings. Health affairs (Project Hope). 2013;32(7):1251-7.

Lemstra M, Blackburn D, Crawley A, Fung R. Proportion and Risk Indicators of Nonadherence to Statin Therapy: A Meta-analysis. Canadian Journal of Cardiology. 2012;28(5):574-80.

Mann BS, Barnieh L, Tang K, Campbell DJ, Clement F, Hemmelgarn B, et al. Association between drug insurance cost sharing strategies and outcomes in patients with chronic diseases: a systematic review. PloS one. 2014;9(3):e89168.

Mathes T, Pieper D, Antoine SL, Eikermann M. Adherence influencing factors in patients taking oral anticancer agents: a systematic review. Cancer epidemiology. 2014;38(3):214-26.

Murphy CC, Bartholomew LK, Carpentier MY, Bluethmann SM, Vernon SW. Adherence to adjuvant hormonal therapy among breast cancer survivors in clinical practice: a systematic review. Breast cancer research and treatment. 2012;134(2):459-78.

Tang KL, Barnieh L, Mann B, Clement F, Campbell DJ, Hemmelgarn BR, et al. A systematic review of value-based insurance design in chronic diseases. The American journal of managed care. 2014;20(6):e229-41.

van der Laan DM, Elders PJM, Boons C, Beckeringh JJ, Nijpels G, Hugtenburg JG. Factors associated with antihypertensive medication non-adherence: a systematic review. Journal of human hypertension. 2017;31(11):687-94.

Co-payments for pharmaceuticals (patients in vulnerable or socio-economically disadvantaged groups)

Park YJ, Martin EG. Medicare Part D's Effects on Drug Utilization and Out-of-Pocket Costs: A Systematic Review. Health services research. 2017;52(5):1685-728.

Pimentel CB, Lapane KL, Briesacher BA. Medicare part D and long-term care: a systematic review of quantitative and qualitative evidence. Drugs & aging. 2013;30(9):701-20.

Polinski JM, Donohue JM, Kilabuk E, Shrank WH. Medicare Part D's effect on the under- and overuse of medications: a systematic review. Journal of the American Geriatrics Society. 2011;59(10):1922-33.

Shenolikar R, Bruno AS, Eaddy M, Cantrell C. Sensitivity of medication use to formulary controls in medicare beneficiaries: a review of the literature. American health & drug benefits. 2011;4(7):465-74.

Sinnott SJ, Buckley CM, O'Riordan D, Bradley C, Whelton H. The effect of copayments for prescriptions on adherence to essential medicines in publicly insured populations; a systematic review and meta-analysis. International Journal of Pharmacy Practice. 2013;21:14.

Choi YJ, Smaldone AM. Factors Associated With Medication Engagement Among Older Adults With Diabetes: Systematic Review and Meta-Analysis. The Diabetes educator. 2018;44(1):15-30.

SBU Enquiry Service consists of systematic literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed. The quality of the studies identified is not systematically reviewed.

Published: 5/9/2018
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