title: Development of a novel, objective measure of health care-related financial burden for U.S. families with children.
abstract: OBJECTIVE
  To develop and validate a theoretically based and empirically driven objective measure of financial burden for U.S. families with children.
  
  
  METHODS
  The measure was developed using 149,021 families with children from the National Health Interview Survey, and it was validated using 18,488 families with children from the Medical Expenditure Panel Survey.
  
  
  METHODS
  We estimated the marginal probability of unmet health care need due to cost using a bivariate tensor product spline for family income and out-of-pocket health care costs (OOPC; e.g., deductibles, copayments), while adjusting for confounders. Recursive partitioning was performed on these probabilities, as a function of income and OOPC, to establish thresholds demarcating levels of predicted risk.
  
  
  RESULTS
  We successfully generated a novel measure of financial burden with four categories that were associated with unmet need (vs. low burden: midlow OR: 1.93, 95 percent CI: 1.78-2.09; midhigh OR: 2.78, 95 percent CI: 2.49-3.10; high OR: 4.38, 95 percent CI: 3.99-4.80). The novel burden measure demonstrated significantly better model fit and less underestimation of financial burden compared to an existing measure (OOPC/income ≥ 10 percent).
  
  
  CONCLUSIONS
  The newly developed measure of financial burden establishes thresholds based on different combinations of family income and OOPC that can be applied in future studies of health care utilization and expenditures and in policy development and evaluation.
authors.affiliation: Center for Child Health Care Studies, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, MA; Department of Population Health Sciences, School of Medicine and Public Health University of Wisconsin, Madison, Madison, WI.
authors.forename: Lauren E
authors.initials: LE
authors.lastname: Wisk
authors.forename: Ronald
authors.initials: R
authors.lastname: Gangnon
authors.forename: David J
authors.initials: DJ
authors.lastname: Vanness
authors.forename: Alison A
authors.initials: AA
authors.lastname: Galbraith
authors.forename: John
authors.initials: J
authors.lastname: Mullahy
authors.forename: Whitney P
authors.initials: WP
authors.lastname: Witt
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D017281:Cost of Illness; D005190:Family; D005102:Health Expenditures; D006301:Health Services Needs and Demand / Q000706:statistics & numerical data; D006801:Humans; D007182:Income / Q000706:statistics & numerical data; D007223:Infant; D008875:Middle Aged; D014481:United States; D055815:Young Adult
keywords: Financial burden; access to health care; families with children; health care costs; measurement; unmet health care need