Out-of-Pocket Expenditure (OOPE) Among COVID-19 Patients by Insurance Status in a Quaternary Hospital in Karnataka, India

Rajesh Kamath, Chris Sebastian, Varshini R. Jayapriya, Siddhartha Sankar Acharya, Ashok Kamat, Helmut Brand, Reshma Maria Cocess D’Souza, Prajwal Salins, Aswin Sugunan, Sagarika Kamath, Sangita G. Kamath () and Sanjay B. Kini ()
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Rajesh Kamath: Department of Healthcare and Hospital Management, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, India
Chris Sebastian: Department of Healthcare and Hospital Management, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, India
Varshini R. Jayapriya: Department of Healthcare and Hospital Management, Prasanna School of Public Health, Manipal Academy of Higher Education, Manipal 576104, India
Siddhartha Sankar Acharya: Department of Medical Administration, Tata Memorial Hospital, Mumbai 400012, India
Ashok Kamat: Department of Psychiatry Nursing, Vijaya College of Nursing Sciences, Belagavi 590010, India
Helmut Brand: Department of International Health, Care and Public Health Research Institute—CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands
Reshma Maria Cocess D’Souza: Department of Medical Laboratory Technology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal 576104, India
Prajwal Salins: Department of Medical Laboratory Technology, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal 576104, India
Aswin Sugunan: Department of Hospital Administration, Yenepoya (Deemed to Be University), Mangalore 574153, India
Sagarika Kamath: Department of International Health, Care and Public Health Research Institute—CAPHRI, Faculty of Health, Medicine and Life Sciences, Maastricht University, 6200 MD Maastricht, The Netherlands
Sangita G. Kamath: Department of Pharmacology, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal 576104, India
Sanjay B. Kini: Department of Community Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal 576104, India

IJERPH, 2025, vol. 22, issue 8, 1-11

Abstract: Out-of-pocket expenditure (OOPE) comprises 62% of national health expenditure in India. This heavy reliance on direct payments has engendered economic vulnerability and catastrophic financial pressures (typically defined as out-of-pocket spending exceeding a certain threshold of household income, leading to financial hardship) on households in a country where public health spending remains below targeted levels. The onset of the COVID-19 pandemic intensified these financial hardships further, as both total healthcare spending and OOPE experienced significant escalations due to the increased need for emergency care, vaccination efforts, and expanded health infrastructure. A retrospective, single-center study was conducted using data from COVID-19 patients admitted between June 2020 and June 2022. Patient data were collected from the Medical Records, IT, and Finance departments. A validated proforma was used for data extraction. Descriptive statistics were calculated, and the Shapiro–Wilk test was applied to assess normality of billing and OOPE data. Patients were stratified into three groups based on their insurance status, allowing for comparative analysis of OOPE percentages and absolute expenditures. The 2715 COVID-19 patients were categorized into three groups according to their health financing: those covered under AB-PMJAY (42.76%), private health insurance (22.16%), and the uninsured (35%). While the median billing amounts were comparable across these groups (ranging between INR 85,000 and INR 90,000), a substantial disparity was observed in terms of financial burden. All patients covered under AB-PMJAY incurred no OOPE, whereas privately insured patients had a median OOPE that constituted approximately 21% of their total billing amounts, with significant variability among different insurers. The uninsured group represented 35% of the cases and experienced the highest median OOPE, indicating substantial financial risk. The COVID-19 pandemic has revealed critical gaps in India’s health financing framework. This study emphasizes the strong financial protection provided by AB-PMJAY, while also exposing the limitations of private health insurance in shielding patients from substantial healthcare costs. As the country progresses toward universal health coverage, there is a pressing need to expand public health insurance schemes that are inclusive, equitable, and effectively implemented. Additionally, strengthening regulation and accountability in the private insurance sector is essential. The study findings reinforce that AB-PMJAY has been highly successful in reducing OOPE and enhancing financial risk protection. Although private insurance reduced OOPE, patients still faced considerable expenses. The stark difference in OOPE of 100% for uninsured patients, 21.16% for privately insured, and 0% for AB-PMJAY beneficiaries underscores the importance of further expanding AB-PMJAY to reach more vulnerable populations.

Keywords: out-of-pocket expenditure; COVID-19; AB-PMJAY; private health insurance; uninsured patients (search for similar items in EconPapers)
JEL-codes: I I1 I3 Q Q5 (search for similar items in EconPapers)
Date: 2025
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