title: Should co-payments for financially deprived patients be lowered? Primary care physicians' perspectives using a mixed-methods approach in a survey study in Tokyo.
abstract: Japan's stagnant economy has produced increasing income disparities, and the effect of poverty on health and health-care utilization is a significant issue. Co-payments could be a trade-off for patients when seeking medical care and limit health-care utilization. We sought primary care physicians' experiences in dealing with financially deprived patients and their perspectives about reducing co-payments by low-income patients.
  
  
  
  We used a convergent mixed-methods approach in a mail survey; it was distributed to 1989 primary care physicians practicing in areas with the highest proportions of socially disadvantaged individuals in Tokyo. The survey items included an open-ended question, seeking the participants' perspectives about reducing co-payments by low-income patients from the current 30%, and closed questions, asking their experience of patient behavior related to financial burdens during the previous 6 months.
  
  
  
  We analyzed the responses of 365 physicians. Sixty-two percent of the primary care physicians agreed with lowering co-payments for financially deprived patients; however, the remainder disagreed or were uncertain. Those who disagreed were less likely to have experienced patient behavior related to financial burdens. The participants suggested challenges and potential measures for reducing co-payments by low-income patients in light of tight governmental financial resources and rapidly increasing health-care expenditures in Japan. The physicians were also concerned about the moral hazard in health-care utilization among patients receiving social welfare who obtain care at no cost.
  
  
  
  From their experience in having dealt with low-income patients, the majority of physicians were positive about lowering co-payments by such patients; the remainder were negative or uncertain. It may be necessary to raise awareness of patients' socioeconomic status among primary care physicians as a possible deterrent for seeking care. To maintain health-care equity, policy makers should consider balancing co-payments among individuals with differing financial levels and health-care needs.
authors.affiliation: Beth Israel Deaconess Medical Center, Harvard Medical School, 1309 Beacon St, Brookline, MA, 02446, USA. machiko-inoue@umin.ac.jp.
authors.forename: Machiko
authors.identifier: 0000-0002-0799-5894
authors.initials: M
authors.lastname: Inoue
authors.affiliation: Department of Hygiene and Public Health, Nippon Medical School, 1-1-5, Sendagi, Bunkyo-ku, Tokyo, 113-8602, Japan.
authors.forename: Yuko
authors.initials: Y
authors.lastname: Kachi
mesh_terms: D000328:Adult; D000368:Aged; D001291:Attitude of Health Personnel; D005260:Female; D005382:Financing, Personal; D005102:Health Expenditures; D006801:Humans; D007182:Income; D007564:Japan; D008297:Male; D008483:Medical Assistance; D008875:Middle Aged; D058007:Physicians, Primary Care; D011203:Poverty; D011320:Primary Health Care; D012923:Social Class; D011795:Surveys and Questionnaires; D014041:Tokyo
keywords: Co-payment; Financial burdens; Health-care equity; Japan; Primary care physicians