Journal of Health & Medical Economics

Keywords

Health insurance knowledge; Health insurance literacy; Health insurance coverage; Health insurance information; Health insurance policies; Universal health insurance

Introduction

The extent of health insurance literacy among the population plays a significant role in their decision to postpone or even avoid seeking medical treatment due to financial concerns and in their perception of their overall health status, which in turn has implications for achieving improved health outcomes in the population [1-5]. Literacy in health insurance has been defined in a variety of forms in the literature. A widely cited definition is proposed by Quincy, 2012 in which health insurance literacy is defined as “the degree to which individuals have the knowledge, ability and confidence to find and evaluate information about health plans, select the best plan for their own (or their family’s) financial and health circumstances and use the plan once enrolled” [6].

Despite its significance, most individuals lack adequate knowledge of their health insurance policy. For example, one study observed that the majority of those with health insurance (90%) had some knowledge of their coverage; however, these individuals had limited knowledge regarding their policy's coverage of outpatient services and pharmaceuticals, underestimating the extent of such coverage [7]. Another study revealed that less than one-third provided accurate answers to four inquiries on fundamental aspects of their insurance plans' coverage [8]. Moreover, Garnick et al., indicated that individuals who owned health insurance demonstrated a relatively high level of accuracy when determining whether their policy encompassed hospital and physician visits; however, their accuracy significantly declined when assessing whether or not their policy comprised mental health coverage or provided coverage for visits to emergency rooms [9,10]. In Saudi Arabia, it was shown that individuals with health insurance generally exhibit a low level of detail from insurance companies, resulting in a limited understanding of the fundamental concepts behind their insurance policies [11].

The primary objective of governments in health insurance markets is to enhance the accessibility of insurance coverage for those lacking insurance [12]. In Saudi Arabia, the government aims to provide complimentary public healthcare via a national health insurance program and instigate transformative changes within its healthcare system [13,14]. Therefore, in 1999, the implementation of Compulsory Employment-Based Health Insurance (CEBHI) was initiated in Saudi Arabia; within the framework of the CEBHI system, it is the responsibility of the employer to bear the financial burden associated with healthcare services provided in the private sector [15]. The cooperative health insurance coverage includes all individual workers employed in the private sector, as well as their respective families [16]. Furthermore, the comprehensive health insurance policy governs the provision of essential medical evaluations, therapies, drugs, ambulatory and hospital-based diagnostic procedures, as well as dental and pharmaceutical services [17].

Understanding the level of consumers' knowledge about health insurance is crucial in delivering high-quality healthcare services. However, it is determined that people who are confronted with too much or too little information often exhibit suboptimal decision-making processes [10]. Additionally, consumers may exhibit poor decision-making tendencies when confronted with alternatives that include an excessive degree of complexity [10]. In Saudi Arabia, researchers have conducted empirical research to assess the level of public knowledge on many health-related topics that extend outside the realm of health insurance. These topics include the range of medical services accessible to individuals as well as the numerous classifications of health conditions [17,18]. Based on the results of the 2018 Saudi Family Health Survey, it was observed that the possession of health insurance knowledge is positively associated with an increased likelihood of seeking medical consultations [19]. In another study, it was observed that participants exhibited a limited level of awareness and knowledge pertaining to health insurance [20].

The inadequate understanding of health insurance among consumers is anticipated to result in various implications. It is important to note that a lack of comprehensive information may sometimes result in actions that are not ideal [21]. Furthermore, if customers lack comprehension of their health insurance plans, it is improbable that they would effectively react to the incentives included in those policies [22]. Individuals who exhibit a thorough knowledge of their health insurance coverage are more inclined to make informed decisions that align with the cost-effective options advocated by their insurance plans. For instance, insured individuals are more likely to choose to visit an urgent care center instead of an emergency room when the former is deemed more suitable [10].

Although there has been much research and assessment conducted on health literacy, the same level of attention has not been given to health insurance literacy, especially health insurance knowledge in Saudi Arabia. Thus, the purpose of this study is to broaden our understanding and measure the level of health insurance knowledge among adults with health insurance in Saudi Arabia, as well as to identify any correlations between this knowledge and socio demographic and occupational variables. We believe the findings of this research will contribute to a greater understanding of health insurance, as it plays a crucial role in the affordability and accessibility of healthcare in Saudi Arabia.

Methodology

Study design

We conducted a cross-sectional design study by recruiting a sample of insured adults in Saudi Arabia. The recruitment process started by acquiring a pool of health insurance consumers from a large insurance company. The study's inclusion criteria consisted of adult individuals who were residents, aged 18 years or older and had health insurance coverage. By random selection, a sample was selected with the following inclusion criteria: Individuals who are 18 years old or older and have health insurance. A sample of 385 participants was required based on sample size calculations with a confidence level of 95%, a 5% margin of error and a population of 10 million based on the latest data from the Saudi Council of Health Insurance report [23].

Participants were invited to complete an online questionnaire while ensuring their anonymity. The invitation included comprehensive details pertaining to the study's contextual framework, aims, methodologies, anticipated duration for survey completion, researcher's contact particulars and assurances regarding privacy and confidentiality, as well as the provision for opting out if desired. In order to participate in the survey, participants were required to provide informed consent on the introductory webpage. Participants were not provided with any incentives and the collection of personally identifiable information was not undertaken. The online questionnaire contained items to assess the participant's demographics and level of knowledge of health insurance (Table 1). Table 2 shows the participant's demographics. Participants were mostly Saudi nationals (91%), between 18 and 40 years old (87%), two-thirds were male, half had a bachelor's degree and half were single.

Table 1: Socio-demographic characteristics of the participants (n=378).

Table 2: The percentage of participants that responded affirmatively to the knowledge level questions.

Measures

Health insurance knowledge was measured by 19 items adapted from the literature and reviewed by the authors (Table 2) [24,25]. These items were designed to evaluate the extent of individuals' understanding of health insurance policy coverage and their awareness of the copayment system. For instance, “do you know your health insurance policy covers emergency health care services?” The participant had the choice between "yes" and "no" as an answer. One point was granted for a response of "no" and two points were awarded for "yes". The aggregate construct of health insurance knowledge was derived by summing the scores of the 19 distinct items. Thus, the range of overall knowledge about health insurance among the participants was from 19 to 38. Using Cronbach's alpha, we were able to determine the level of internal consistency (reliability) of the construct and we found that it was high at 0.91.

Data analysis

The online survey was conducted using the survey monkey platform. Subsequently, all data were exported to SPSS 23.0 software for the purpose of data cleaning and analysis. The primary objective of the initial analysis was to gather descriptive statistics, including frequencies, proportions and mean scores, for all variables. In order to assess potential relationships, a multiple regression analysis was conducted following the verification of test assumptions. The study estimated standardized beta coefficients and their corresponding 95% confidence intervals in order to analyze the associations between the outcome variable and the predictors. A significance level of α <0.05 was employed to determine statistical significance.

Results

The objective of this study was to assess the extent of health insurance knowledge among adults with health insurance in Saudi Arabia and to examine potential associations between health insurance knowledge and socio demographic and other related factors.

Table 1 shows participant’s socio demographic variables and other related factors. The findings show that participants obtained information about health insurance services from health insurance providers (38.2%), family and friends (26%) and official sources (12%). Additionally, it was observed that participants mainly got health insurance because their employers required it (65.6%) and 24% to cover medical expenses.

The participant's overall level of knowledge of health insurance varied between 19 and 38, with a mean value of 28.9 and a standard deviation of 5.4. Following a detailed examination of the 19 items pertaining to the degree of knowledge about health insurance, it was evident that there was a considerable variation in the percentage of participants exhibiting a high level of knowledge (Table 2). Approximately 70% of the participants demonstrated awareness of health insurance coverage for dental and optical care. A limited proportion of individuals, around 25%, have knowledge of the upper limit of their copayment expenses. It is significance to emphasize that only 38% of the participants showed awareness about the provision of preventive health care services within their health insurance coverage and only 46% had information concerning the inclusion of medical equipment.

Three variables have been shown to be significantly correlated with the participants' degree of health insurance knowledge: Marital status, the sources of health insurance information and years of having health insurance (Table 3). The findings indicate that single individuals, on average, have a lower degree of knowledge about health insurance compared to their married counterparts (β=-0.13, p=0.02). Participants who acquired knowledge about health insurance through family and friends had a greater degree of knowledge in comparison to those who gained information only from their health insurance provider's sources (β=0.18, p<0.001). However, participants who obtained their knowledge about health insurance from official governmental sources had a comparatively lower degree of knowledge in contrast to those who obtained information from provider sources (β=-0.12, p=0.02). Additionally, it was observed that individuals with a greater number of years of health insurance coverage had a better level of knowledge. Individuals with less than one year (β=-0.25, p<0.001) and one to five years (β=-0.15, p=0.02) of health insurance coverage had lower levels of knowledge in comparison to those with more than ten years of health insurance coverage.

Table 3: The regression analysis of the relationship between knowledge about health insurance and demographic characteristics.

Discussion

The main aim of this study was to assess the level of knowledge about health insurance among the population of insured adults in Saudi Arabia. This study evaluates current levels of knowledge about health insurance and its association with socio demographic and other pertinent factors. The results indicated that the participants exhibit a moderate level of knowledge regarding health insurance, with substantial differences observed in their comprehension of certain aspects of their health insurance policy. Additionally, we found a significant correlation between participants' level of health insurance knowledge and their marital status, sources of health insurance information and duration of health insurance coverage.

Recent research conducted in Saudi Arabia has revealed a limited level of awareness regarding health insurance [20]. In our study, the participants demonstrated moderate levels of knowledge regarding health insurance. While such levels may be deemed acceptable it falls short of the anticipated level of knowledge based on the available and easily accessible information pertaining to health insurance policies. A significant proportion of the participants demonstrated a lack of awareness regarding several crucial components of the health insurance policy. Notably, the inclusion of preventive services within insurance policies is a topic that a majority of the participants were unaware of. Despite the provision of preventive services for several years, there persists a state of confusion and inadequate awareness regarding the specific services that are encompassed within the coverage. A study conducted in the US showed that the percentage of respondents who accurately answered questions pertaining to their current coverage was found to be 38.6% [26]. Another research found that only 36.4% of adults knew about the affordable care act's mandate of providing coverage for specific preventive services without any associated cost-sharing [27]. One potential explanation for the insufficient knowledge may stem from a public misconception that insurance coverage is accessible for screenings pertaining to unobserved conditions like hypertension while being inaccessible for conditions that are more apparent or perceived to be linked to personal health behaviors, such as obesity [26].

Participant’s marital status, sources of health insurance information and duration of health insurance coverage were found to have a significant correlation with the level of health insurance knowledge. The level of knowledge regarding health insurance coverage and policies was found to be higher among married participants in comparison to their single counterparts. This phenomenon can be attributed to the collective knowledge possessed by married couples, more use of healthcare services by married couples, as well as the increased sense of responsibility that comes along with marriage [28]. However, our results were contradicted by other research that found singles exhibited a significantly higher level of awareness in comparison to their married counterparts [29]. Our findings also showed that participants relied on their family and friends for information regarding their health insurance. Similar findings were observed in various contexts, including the level of diabetes knowledge among individuals diagnosed with diabetes [30]. There was a positive correlation observed between the length of time individuals had health insurance coverage and their level of knowledge regarding health insurance. These outcomes are anticipated as knowledge tends to accrue over time and through exposure to transactions within healthcare services.

There exist several limitations inherent to our study that may be potentially addressed in future research. The study was susceptible to potential information and recall bias as a result of employing a self-reporting methodology. Furthermore, the research methodology utilized in this study encompassed the implementation of a cross-sectional survey methodology, which relied on the collection of self-reported data. Therefore, it is crucial to acknowledge the difficulty in establishing causality based on these findings. Furthermore, as a result of limited resources, we implemented a convenient sampling methodology that may not provide an accurate representation of the larger population.

Conclusion

In general, despite several years of implementing health insurance coverage in Saudi Arabia, knowledge of health insurance remains below the desired level. The absence of essential information may result in a knowledge deficit that could impede individuals' capacity to make informed decisions regarding healthcare-seeking behavior, potentially having adverse effects on the overall health of the population. Thus, it is imperative to implement new and effective approaches and policies aimed at enhancing the public's knowledge regarding the accessibility and scope of healthcare services.

Ethical Consideration

We obtained approval from the research ethics committee of the Saudi Electronic University to conduct the study. We adhered to the ethical guidelines set forth by the institutional research committee and followed the 1964 Helsinki declaration, along with its subsequent amendments or similar ethical standards, in conducting all procedures involving human participants.

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