In this study, the estimated mean of age at diagnosis, the age of patients and age at death was 45.41, 47.98 and 49.94 years old, respectively. In our study, the mean age of patients was 47.98 years old, while in Davari et al. (2013), the mean age of patients estimated at 49 years old, in Iran (30). So it can be concluded that the age of breast cancer onset has decreased in Iran in recent years. The average mortality age of breast cancer is still lower than other cancers, and the economic burden of this disease will rise in the predictable future, according to one study in Japan (21).
In this study, the total mean cost of breast cancer among patients who referred to the public hospital was 1.92 times greater than those referring to the private hospitals (76630 PPP current international $ VS 41460 PPP current international $). The results showed that direct costs were the major component of the total costs of patients with breast cancer who referred to the private hospital, whereas the major component of the total cost of those referring to the public hospital was related to the indirect costs.
The indirect cost of patients who referred to the public hospital was 11.94 times as much as than those referring to the private hospital, and this difference was statistically significant. In contrast, the estimated mean medical direct cost of patients who referred to the private hospital was 2.73 times greater than those referring to the public hospital (34264.12 PPP $ VS 12536.16 PPP current international $). Considering the significant amount of medical costs. In the study of T. A. Dinesh et al., in India, there was a significant difference in the direct cost of care for cancer in private hospitals ($27,425 vs $21,2320), whereas the indirect cost of care for cancer was significantly higher in government hospitals ($10,340 vs $6565) (31). A study by Kounichika et al. in Japan indicated that the mortality costs accounted for 65-70% of the total cost (21), which the results of these studies are in line with our results.
The difference between direct and indirect costs in patients referred to private and public hospitals may be due to several reasons. Firstly, premature death was the major component of the total indirect cost of breast cancer patients who referred to the public hospital, whereas that did not occur among breast cancer patients in the private hospital. This may be because private hospitals offered better services which resulted in a higher survival rate and a lower mortality rate. Besides, given that the mean age of patients with breast cancer referring to the public hospital (49.776.66 (9.89)) was higher as compared with those referring to the private hospital (46.66 (10.06)), and this difference was statistically significant (p<0.05), the high mortality rate in the public hospital can be because most of the older patients referred to the public hospital. On the other hand, patients with advanced-stage cancer likely referred more to public hospitals for receiving services. Secondly, none of the patients who referred to the public hospital had supplementary insurance, while most of the patients who referred to the private hospital, in addition to basic health insurance, were covered by supplemental insurance. Supplemental insurance has increased patients access to more advanced and expensive treatment services and has made services more inelastic by reducing the patients’ co-payment or have led to increased induced demand. In this study, the correlation between direct medical costs, outpatient costs, chemotherapy costs and age at diagnosis was statistically significant and negative at P<0.05.
Thirdly, tariffs in the private sector are 2-4 times higher than that of the public sector. Therefore, direct medical costs are higher in patients referring to the private sector.
Of note, in Iran, only people who have better socio-economic status and better income level are able to afford supplemental health insurance and refer to the private sector for receiving treatment, which in turn cause they receive more expensive and advanced services. Hence, it may cause the mortality rate among those to refer to the private hospital to be lower and incur lower indirect costs, but due to more treatment services utilization, they are more likely to incur greater direct medical costs than those referring to the public hospital.
Of the direct medical costs, outpatient costs were higher than hospitalization costs in both private and public hospitals. The outpatient cost of patients who referred to the private hospital was 3.4 times greater than those referring to the public hospital. The major component of outpatient diagnostic costs of patients who referred to the private and the public hospitals was related to diagnostic costs. The results of our study suggest that more attention should be paid to the management of outpatient costs for breast cancer patients in both private and public hospitals. The study by Allaire et al. in the US reported that the outpatient costs caused by breast cancer were equivalent to 94% of the total cost of breast cancer (32). In the study of Ekwueme et al., the estimated monthly direct medical costs for breast cancer treatment among younger women enrolled in Medicaid was $5,711 per woman. The estimated monthly cost for outpatient services was $4,058, for inpatient services was $1,003, and for prescription drugs was $539 (33).
Furthermore, the hospitalization costs of patients who referred to the private hospital were 1.46 times greater than those referring to the public hospital. This difference may, in part, be because of the different tariffs or difference in the type of provided services. The most component of total hospitalization cost of patients who referred to the private hospital was related to surgery cost, whilst that of patients who referred to the public hospital was attributable to hoteling cost. In the study of Davari et al., in 2013, in Iran, most of the treatment costs were related to drug therapy (30). In the study of Omondi Michelle et al., in 2016, patients on chemotherapy alone cost an average of $1364.3; while those treated with surgery cost an average of $1265.6, and those on radiotherapy $1175.1 (34). A study by Elias et al. showed that the average annual cost of cancer drugs was 6.475$ per patient, which the highest amount of drug costs were related to breast cancer (35).
In the private hospital, the mean of chemotherapy cost for those who had received chemotherapy estimated at $1450 per patient, making up %14.67 of the total medical costs while in the public hospital was $550 per patient, which accounted for %15.13 of the total medical costs Likewise, The mean of radiotherapy cost for those who had received radiotherapy in the private hospital and the public hospital was estimated to be $680 (%6.88 of the total medical costs) and $189 (%5.22 of the total medical costs) per patient, respectively. Moreover, the total direct nonmedical cost of patients who referred to the public hospital was 2.03 times greater than those referring to the private hospital. At both hospitals, commuting costs accounted for the highest component of the total nonmedical direct cost of patients.
The total cost of missed workdays for the patient and the patient’s family, who referred to the private hospital was 1.7 times greater than those referring to the public hospital. Both in the private and the public hospital, the cost of missed workdays of patient’s family members was greater than patients themselves. These costs (opportunity cost) are imposed on patients' families in real terms but are hidden from policymakers' view.
In our study, basic insurance played an important role in the reimbursement of direct medical costs and reducing the proportion of out-of-pocket expenses in direct medical costs. The majority of breast cancer costs in public hospitals was paid by basic insurance (%90.68), %6.39 of the costs were paid by the patient, and only a small proportion was paid from the targeted subsidy plan by the government (%2.92). To the contrary, in the private hospitals, %35.36 of costs was reimbursement by supplemental insurance, %37.85 of costs was reimbursement by basic insurance, and the remaining %26.77 of costs (6.04 greater than those referring to the public hospitals) was paid by patients. The total out of pocket payments in the private hospital estimated at $3881.23 (approximately 0.38 of total direct costs and 2.83 times higher than in the public hospital), while in the public hospital was $1367.19 (about 0.34 of total direct costs).
It is important to note that although most of the cancer patients in the private sector were covered by supplemental insurance, they paid higher co-payments. Since tariffs in the private sector are 2-4 times higher than that of the public sector, patients referring to private hospitals paid more out of pocket payments despite supplemental insurance. Therefore, these patients are likely to have better socio-economic status and more ability to pay. On the other hand, despite higher costs, these patients may prefer to go to private hospitals because of the shorter waiting time and better service quality.
Since the present study was performed at cross-sectional and prevalence-based method, matching was not conducted between patients referring to the public and the private hospitals in terms of age, income level and disease stage and also the effect of confounding variables was not controlled. Since it is not possible to conclude with any certainty, it is necessary to investigate the cause of this difference in costs and mortality rate between patients referring to the public and the private hospitals in future studies using a perspective and controlled design. In Multivariate regression model after adjusting for confounding variables (e.g., age, education status, marital status, habitation status, type of basic insurance and supplemental insurance status), hospitalization costs in patients referring to private hospitals were significantly higher than those referring to the public hospital.
This study had several limitations. First, since some patients refused to answer the questions asked of them, the selection bias (sampling bias and attrition) of respondents in reviewing the costs could not be avoided. Second, the indirect costs consisted of only the missed workdays and premature mortality, which would greatly undervalue the indirect economic burden of illness. The lack of data on permanent leaving the job by patients and caregivers during the recovery period could also underestimate the indirect cost estimates. Third, the cost of breastfeeding was not calculated due to the paucity of data. Fourth, intangible economic costs of breast cancer patients and their families, including the pain, sorrow, were not included because they are difficult to convert into a monetary value (36). Given this was a cross-sectional and prevalence-based study, matching was not conducted between patients referring to the public and the private hospitals in terms of age, income level and disease stage and also the effect of confounding variables were not controlled. An additional limitation is that this study conducted in only two private and public hospitals that can limit the generalization of study findings to all private and public sector.
Given that the cost of premature death in the private hospital was zero, it is not possible to conclude with certainty whether cancer patients who referred to the public hospital were at the final stage of the disease or benefited from better services or both? If the low mortality rate and low indirect costs in patients referred to the private hospital be attributed to the quantity and quality of services provided to cancer patients referring to the private sector and considering the high share of indirect costs of total costs in patients referred to the public hospital, it is necessary that health policymakers take the necessary measures to improve the quantity and quality of public sector services. Also, despite the insurance coverage, patients suffer a high amount of OOP payment, a substantial and wide-ranging effort is needed to support breast cancer patients. This suggests that insurance policies need to be revised to increase financial support among cancer patients, especially for those who are currently uninsured. It is recommended that the results of this study to be used in future studies to evaluate the cost-effectiveness of screening interventions, early detection and preventive interventions, and health policymakers take an appropriate policy to reduce the economic burden of this disease. It is also suggested that future studies should examine whether the higher costs in private hospitals is due to disparities in tariffs of the private and public sector or due to greater quantity and quality services provided in private hospitals.