title: The impact of out-of-pocket payments on prevention and health-related lifestyle: a systematic literature review.
abstract: BACKGROUND
  Out-of-pocket payments can have a large impact on the demand for healthcare. They can be essential not only to decrease unnecessary service use, but also to encourage the use of particular preventive services provided free of charge or at a lower price. Moreover, out-of-pocket payments may increase the costs of unhealthy behaviour and provide incentives for a healthier lifestyle.
  
  
  METHODS
  This study systematically reviews empirical evidence on the effects of out-of-pocket payments on the use of preventive services and health-related lifestyle. All possible combinations of three key words 'prevention', 'patient payment' and 'health-related behaviour' were searched in PUBMED, ECONLITH, ECONPAPER and EMBASE. In total, 47 relevant publications were identified.
  
  
  RESULTS
  The results suggest that out-of-pocket payments can create a financial barrier and can decrease the use of preventive services and the uptake of preventive medications. A few studies (with contradicting empirical evidence) address the impact of cost sharing and reduced insurance coverage on a healthier lifestyle.
  
  
  CONCLUSIONS
  Although the great diversity of study designs (various indicators of out-of-pocket payments and preventive/health-related behaviour) makes it difficult to offer robust policy recommendations, our findings support calls to reconsider how preventive services should be financed. More research is needed to explore the actual impact of cost sharing on different aspects of health-related lifestyles, as well as to explain the role of other relevant determinants that could impact this relationship.
authors.affiliation: Department of Health Services Research, CAPHRI, Maastricht University Medical Center, Faculty of Health, Medicine and Life Sciences, Maastricht University, The Netherlands. mr.rezayatmand@maastrichtuniversity.nl
authors.forename: Reza
authors.initials: R
authors.lastname: Rezayatmand
authors.forename: Milena
authors.initials: M
authors.lastname: Pavlova
authors.forename: Wim
authors.initials: W
authors.lastname: Groot
mesh_terms: D001294:Attitude to Health; D017047:Cost Sharing / Q000191:economics*; D005382:Financing, Personal / Q000191:economics*; D015438:Health Behavior; D005102:Health Expenditures / Q000706:statistics & numerical data*; D006801:Humans; D007348:Insurance, Health / Q000191:economics; D008019:Life Style; D011314:Preventive Health Services / Q000191:economics* / Q000706:statistics & numerical data; D055502:Secondary Prevention / Q000191:economics