Financial toxicity (FT) is the impact that out of pocket (OOP) costs of cancer care have on patients' well-being, leading to lower quality of life, less compliance with prescribed therapy, and poorer outcomes, including increased mortality. The purpose of this study was to understand the impact of FT on advanced cancer patients' lives and their health care decision-making. Fuzzy trace theory provided the framework for examining how patients use gist and verbatim when making health care decisions while experiencing FT. Gist refers to main ideas that are often infused with emotional overlays that people use to make risky decisions, while verbatim thinking involves the recall of precise facts and figures to make decisions. The research method was case study that included conducting 13 in-depth interviews, collecting artifacts, and scoring of FT using the Comprehensive Score for Financial Toxicity tool. Findings from two-cycle coding and cross-case analysis indicated that FT and OOP costs have significant impacts on patients' lives and how they make decisions about their cancer care. Participants considered cost as a risk in cancer treatment decisions and encoded this information using verbatim rather than gist, which they used for other dimension of risk in these decisions. Participants reported they would decline care if OOP costs were high and FT was present. When OOP costs were low, participants relied on gist decision-making and generally followed their physicians' recommendations. Findings may assist cancer experts who are investigating FT and its impact on cancer care as well as those who are developing support programs for patients who experience FT.

Pharmaceutical expenditures are an important part of the entire hospital operating budget, and inpatient pharmaceuticals denote one of the highest costs in hospital care. Predictions for medication budgets based on the types of patients have been largely undertaken in medical hospitals and not psychiatric facilities. According to several previous studies, gender, age, diagnosis, comorbidity and length of stay (LOS) affect the general inpatient treatment expenditures. However, whether or not the impact of these factors differs in psychiatric hospitals remains to be investigated. To that end, the current study examines medication costs for mental and behavioral health disorder as well as the primary chronic diseases commonly comorbid with mental and behavioral health disorders that suggest formulary management control might be helpful. Multiple regression models were developed to determine the leading drivers associated with the growing inpatient hospital medication costs among patients admitted to an acute psychiatric hospital. We also analyzed LOS using a Poisson model in order to determine whether it is a proxy for psychiatric inpatient medication costs. Our finding selected 51 medications (14% of the 364 total medications consumed 90% of the total medication cost) under A category (AV, AE, and AN) and B category (BV, BE, and BN) in order to develop a medication list (MUC, medication under control) that suggested cost control measures based on cost and clinical criticality could be important. This study demonstrated that comorbidity, principal and secondary diagnoses, LOS, and MUC are associated with higher inpatient medication costs than other factors, including age, gender, insurance type, and month admitted. Our study also observed that the principal ICD-10-CM codes F10 (Alcohol related disorders) is associated with high inpatient medication cost. Secondary diagnosis related groups (DRGs) 203 (Bronchitis & asthma), 192 (Chronic obstructive pulmonary disease, COPD), 201 (pneumothorax), 639 (Diabetes), 642 (Inborn and other disorders of metabolism), 645 (Endocrine disorders), 641 (Nutritional & miscellaneous metabolic disorders), 690 (Kidney & urinary tract infections), 675 (Other kidney & urinary tract procedures), 699 (Other kidney & urinary tract diagnoses), and 700 (Other kidney and urinary tract diagnoses), 305 (Hypertension), 310 (Cardiac arrhythmia & conduction disorders), 303 (Atherosclerosis), 293 (Heart failure & shock), and 316 (Other circulatory system diagnoses) were found to be associated with higher inpatient medication costs. In addition, LOS can be used as an indicator (proxy) for inpatient medication cost when patients present with a secondary DRG 639 (diabetes) and 690 (kidney & urinary tract infections) in an acute psychiatric hospital. Viewed collectively, this study would enable executives of acute psychiatric hospitals to identify the most important factors that are associated with high inpatient medication costs, thereby assisting in the development of the hospital pharmaceutical budget using a novel and scientific approach.

Au Québec, il est mandatoire d’avoir une assurance médicaments soit privée ou publique. De plus, le coût d’un médicament a trois composantes : le prix de la molécule, la marge bénéficiaire du grossiste et l’honoraire du pharmacien. Les deux premières composantes sont fixes et déterminées par la Régie de l’assurance médicaments du Québec (RAMQ) pour les personnes couvertes par les régimes privés d’assurance médicaments ou le régime public d’assurance médicaments (RPAM). L’honoraire du pharmacien est déterminé par la RAMQ pour les personnes couvertes par le RPAM (entre 8,50$ et 9,49$) alors qu’il est librement déterminé par le pharmacien propriétaire pour les personnes couvertes par les régimes privés d’assurance médicaments ce qui donne lieu à des différences dans le coût des médicaments. Les objectifs de ce mémoire étaient d’estimer la différence de coût et des dépenses des médicaments entre les patients couverts par les régimes privés d’assurance médicaments et le RPAM au Québec. Afin de répondre aux objectifs, les ordonnances remplies entre le 1er janvier 2015 et le 23 mai 2019 ont été sélectionnées de reMed, une banque de données qui contient l’information sur les ordonnances remplies par d’un échantillon de Québécois. Des strates d’ordonnances de médicaments ont été créées afin d’avoir à l’intérieur de chaque strate le même médicament (même DIN), même quantité et durée prescrites, acheté à la même pharmacie avec la même Liste des médicaments de la RAMQ. Chaque strate d’ordonnances remplies par les patients couverts par un régime privé d’assurance médicaments a été appariée à une strate d’ordonnances remplies par des patients couverts par le RPAM sur les mêmes critères utilisés pour la stratification. Des modèles de régression linéaires ont été utilisés afin d’estimer la différence de coût et de dépenses entre les régimes privés d’assurance médicaments et le RPAM. Basée sur 38 896 strates (un total de 162 019 ordonnances), l’étude a montré que globalement le coût d’une ordonnance de médicament est en moyenne 9,35$ (95% CI: 5,58 ; 13,01) plus élevé pour les patients couverts par les régimes privés d’assurance médicaments que pour ceux couverts par le RPAM (62,34$ vs 52,99$). Quant aux dépenses des patients pour une ordonnance de médicament, les patients couverts par un régime privé d’assurance médicaments déboursaient 1,01$ (95% CI: -1,22 ; -0,80) moins que ceux couverts par le RPAM (6.94$ vs 7.95$). Cette étude a montré qu’en moyenne le coût des médicaments est plus élevé et que les dépenses sont légèrement plus faibles pour les patients couverts par les régimes privés d’assurance médicaments. Donc, ces résultats seront utiles pour les décideurs et les autorités gouvernementales lorsqu’ils prendront des décisions éclairées sur les modalités d’assurance au Québec. / In the province of Quebec, it’s mandatory to have a drug insurance either private or public. Also, drug cost in Quebec has three components: ingredient list price, wholesaler markup and dispensing fee. The first two components are regulated by the Prescription drug plan (PDP) and are the same for publicly and privately insured patients. The third component is fixed (between CAD$8.50 and CAD$9.49) and regulated by the PDP for publicly insured patients while it is determined freely by the pharmacy owner for privately insured patients. The objectives of this thesis were to estimate the average difference for both drug and out-of-pocket costs between patients covered by private drug plans and the PDP in Quebec. We used a sample of prescriptions filled between January 1st, 2015 and May 23rd , 2019 selected from reMed, a drug claims database of Quebecers. We created strata of prescriptions filled by privately insured patients based on the DIN, quantity dispensed, number of days of supply, pharmacy identifier and a date corresponding to a publication of RAMQ’s List of Medications. Then, we matched each stratum filled by privately insured patients with a stratum of prescriptions filled by publicly insured patients based on the same stratification criteria. The differences in drug cost and out-of-pocket expenses between private and public drug insurance were analyzed with linear regression models. Based on 38 896 strata of prescriptions (162 019 prescriptions in total), we observed that privately insured patients had to pay CAD$9.35 (95% CI: 5.58 ; 13.01) more on average per drug prescription than publicly insured patients (CAD$62.34 vs CAD$52.99), representing a difference of 17.6%. We also found that out-of-pocket expenses were on average CAD$1.01 (95% CI: -1.22 ; -0.80) lower per drug prescription for privately than publicly insured patients (CAD$6.94 vs CAD$7.95). This study showed that, on average, drug cost is substantially higher and out-of-pocket slightly lower for privately insured Quebecers. Knowing that adherence is affected by drug cost, these results will be useful to help public health authorities to make informed decisions about drug insurance policies.