title: Impact of Treatment Subsidies and Cash Payouts on Treatment Choices at the End of Life.
abstract: OBJECTIVE
  To examine the extent to which financial assistance, in the form of subsidies for life-extending treatments (LETs) or cash payouts, distorts the demand for end-of-life treatments.
  
  
  METHODS
  A discrete choice experiment was administered to 290 patients with cancer in Singapore to elicit preferences for LETs and only palliative care (PC). Responses were fitted to a latent class conditional logistic regression model. We also quantified patients' willingness to pay to avoid and willingness to accept a less effective LET or PC-only. We then simulated the effects of various LET subsidy and cash payout policies on treatment choices.
  
  
  RESULTS
  We identified three classes of patients according to their preferences. The first class (26.1% of the sample) had a strong preference for PC and were willing to give up life expectancy gains and even pay for receiving only PC. The second class (29.8% of the sample) had a strong preference for LETs and preferred to extend life regardless of cost or quality of life. The final class (44.1% of the sample) preferred LETs to PC, but actively traded off costs and length and quality of life when making end-of-life treatment choices. Policy simulations showed that LET subsidies increase demand for LETs at the expense of demand for PC, but an equivalent cash payout was not shown to distort demand.
  
  
  CONCLUSIONS
  Patients with cancer have heterogeneous end-of-life preferences. LET subsidies and cash payouts have differing effects on the use of LETs. Policymakers should be mindful of these differences when designing health care financing schemes for patients with life-limiting illnesses.
authors.affiliation: Health Services and Systems Research Program, Duke-NUS Medical School, Singapore; Duke Global Health Institute, Duke University, Durham, NC, USA. Electronic address: eric.finkelstein@duke-nus.edu.sg.
authors.forename: Eric
authors.initials: E
authors.lastname: Finkelstein
authors.affiliation: Health Services and Systems Research Program, Duke-NUS Medical School, Singapore.
authors.forename: Chetna
authors.initials: C
authors.lastname: Malhotra
authors.affiliation: Health Services and Systems Research Program, Duke-NUS Medical School, Singapore.
authors.forename: Junxing
authors.initials: J
authors.lastname: Chay
authors.affiliation: Health Services and Systems Research Program, Duke-NUS Medical School, Singapore.
authors.forename: Semra
authors.initials: S
authors.lastname: Ozdemir
authors.affiliation: Johns Hopkins Singapore International Medical Centre, Singapore.
authors.forename: Akhil
authors.initials: A
authors.lastname: Chopra
authors.affiliation: Division of Medical Oncology, National Cancer Centre Singapore, Singapore.
authors.forename: Ravindran
authors.initials: R
authors.lastname: Kanesvaran
mesh_terms: D002755:Choice Behavior; D005260:Female; D005382:Financing, Personal / Q000191:economics; D006801:Humans; D016015:Logistic Models; D008297:Male; D008483:Medical Assistance / Q000191:economics*; D008875:Middle Aged; D009369:Neoplasms; D057240:Patient Preference / Q000191:economics*; D011788:Quality of Life; D012846:Singapore; D013727:Terminal Care / Q000379:methods*
keywords: cash payout; palliative care; preference; subsidy