Referral care utilization and financial burden of comorbidities among individuals with pulmonary tuberculosis: A two-part model analysis of Indonesia's national health insurance data, 2022

Abstract

Background: Pulmonary tuberculosis remains a leading infectious disease globally. In Indonesia, coexisting noncommunicable diseases are increasing referral care use and total spending in the National Health Insurance program. Using 2022 national insurance claims data, this study aimed to estimate the financial impact of noncommunicable comorbidities among individuals with pulmonary tuberculosis. Methods: This study follows cross-sectional study design, utilizing the Indonesian National Health Insurance contextual tuberculosis sample data. The study included individuals newly diagnosed with pulmonary tuberculosis in 2022. Individuals were classified into three categories based on the presence of noncommunicable comorbidities: none, single, and multiple. A marginalized two-part model was applied. First, logistic regression was fitted to estimate the likelihood of any referral care utilization. Second, a generalized linear model with a log link and log-normal distribution to analyze positive healthcare expenditures. Result: Noncommunicable comorbidity was strongly associated with higher referral care utilization and greater healthcare expenditures. Compared with individuals without noncommunicable comorbidities, those with one noncommunicable disease had an adjusted odds ratio of 201.22 (95 % CI, 148.77-272.16) and a cost ratio of 1.63 (95 % CI, 1.59-1.68). Individuals with multiple noncommunicable diseases had an adjusted odds ratio of 206.69 (95 % CI, 121.32-352.13) and a cost ratio of 3.23 (95 % CI, 3.10-3.37). The average annual expenditure increased from 188.48 USD among individuals without noncommunicable diseases to 416.85 USD for those with single, and 762.80 USD for those with multiple noncommunicable diseases. A significant (78.23 %) pulmonary tuberculosis individuals without noncommunicable disease comorbidity utilized referral care. Conclusions: This study reports that individuals with pulmonary tuberculosis who also have noncommunicable diseases face a much heavier financial burden within Indonesia's National Health Insurance program. Strengthening primary care and integrating tuberculosis and noncommunicable disease management should be implemented to reduce costs and improve health outcomes. (c) 2025 The Author(s). Published by Elsevier Ltd on behalf of King Saud Bin Abdulaziz University for Health Sciences. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/ 4.0/).