How do People with Multimorbidity Prioritise Healthcare when Faced with Financial Constraints? A Choice Experiment

Multimorbidity is associated with increased out-of-pocket healthcare costs, making people with multimorbidity more vulnerable to cost-related non-adherence to recommended treatment. This study aimed to understand how people with multimorbidity would prioritise different healthcare services and chronic conditions when faced with potential budget constraints. A cross-sectional online survey incorporating a choice experiment was conducted in Ireland (December 2021 to March 2022). Participants were adults aged 40 years or over with at least one chronic condition. They were asked how they would prioritise their real-world healthcare utilisation if their monthly personal healthcare budget were reduced by 25%. The survey also included questions about real-life experiences of cost-related non-adherence and financial burden. Among the 962 participants, 64.9% (n=624) had multimorbidity. When presented with the hypothetical budget constraint, participants reduced expenditure on ‘other healthcare (hospital visits, specialist doctors, etc.)’, by the greatest percentage (50.2%), and medicines by the lowest percentage (24.5%). Participants with multimorbidity tended to have a condition they prioritised over others. On average, they reduced expenditure for their top-priority condition by 69% less than would be expected if all conditions were valued equally, compared to a reduction in expenditure of 59% more than expected for their least prioritised condition. Participants were asked how important several areas were when making their decisions (scale of 1 – ‘not important at all’ to 5 – ‘very important’). Independence, symptom control and staying alive were rated as the most important decision factors (median=5). Over one third (34.5%, n=332) of participants reported cost-related non-adherence as they had either not attended a healthcare professional or not paid for medication or both in the last year due to cost. Research and clinical care must take greater consideration of the different ways people with multimorbidity respond to high healthcare costs and the impact this has on treatment adherence and health outcomes. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement Health Research Board Ireland [CDA-2018-003] funded SMS for this study https://www.hrb.ie/ Include this sentence at the end of your statement: The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Ethical approval for this study was obtained from the RCSI University of Medicine and Health Sciences Research Ethics Committee (202101004) I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Researchers interested in using the data associated with this study may access the data for free from the following sites: Irish Social Science Data Archive (ISSDA) at University College Dublin https://www.ucd.ie/issda/data/choiceexperiment/