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Zhang Q, Laporte A. The impact of prescription drug insurance on cost related non-adherence to medications in Canada: A Heckman sample selection approach. PLoS One 2023; 18:e0289776. [PMID: 37556420 PMCID: PMC10411745 DOI: 10.1371/journal.pone.0289776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 07/25/2023] [Indexed: 08/11/2023] Open
Abstract
Unlike some other high-income counties, Canada does not provide universal prescription drug coverage. The various extent of coverage may left some Canadians vulnerable to cost-related non-adherence (CRNA) to medications. Using data from the 2015 national cycle of the Canadian Community Health Survey, we examine the impact of having private and public drug coverage on mitigating the risk of CRNA with a logit model and a Heckman selection model. CRNA was only observed in respondents who had prescriptions to fill, and respondents did not randomly make decisions on whether to get a prescription. This results in a classic sample selection problem. We found a higher estimated probability of reporting CRNA for uninsured respondents from the Heckman selection model than from the logit model. Respondents with government coverage only had a slightly higher probability of reporting CRNA relative to respondents with private coverage. These findings suggest that, without accounting for sample selection, the risk of not having drug insurance coverage is likely to be underestimated. Moreover, despite covering a less healthy cohort of respondents, the government insurance plans reduce risk of CRNA to a comparable level with private insurance.
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Affiliation(s)
- Qi Zhang
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Canadian Center for Health Economics, Toronto, ON, Canada
| | - Audrey Laporte
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Canadian Center for Health Economics, Toronto, ON, Canada
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Guindon GE, Stone E, Trivedi R, Garasia S, Khoee K, Olaizola A. The Associations of Prescription Drug Insurance and Cost-Sharing With Drug Use, Health Services Use, and Health: A Systematic Review of Canadian Studies. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2023; 26:1107-1129. [PMID: 36842717 DOI: 10.1016/j.jval.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 12/12/2022] [Accepted: 02/17/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVES In Canada, public insurance for physician and hospital services, without cost-sharing, is provided to all residents. Outpatient prescription drug coverage, however, is provided through a patchwork system of public and private plans, often with substantial cost-sharing, which leaves many underinsured or uninsured. METHODS We conducted a systematic review to examine the association of drug insurance and cost-sharing with drug use, health services use, and health in Canada. We searched 4 electronic databases, 2 grey literature databases, 5 specialty journals, and 2 working paper repositories. At least 2 reviewers independently screened articles for inclusion, extracted characteristics, and assessed risk of bias. RESULTS The expansion of drug insurance was associated with increases in drug use, individuals who reported drug insurance generally reported higher drug use, and increases in and higher levels of drug cost-sharing were associated with lower drug use. Although a number of studies found statistically significant associations between drug insurance or cost-sharing and health services use, the magnitudes of these associations were generally fairly small. Among 5 studies that examined the association of drug insurance and cost-sharing with health outcomes, 1 found a statistically significant and clinically meaningful association. We did not find that socioeconomic status or sex were effect modifiers; there was some evidence that health modified the association between drug insurance and cost-sharing and drug use. CONCLUSIONS Increased cost-sharing is likely to reduce drug use. Universal pharmacare without cost-sharing may reduce inequities because it would likely increase drug use among lower-income populations relative to higher-income populations.
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Affiliation(s)
- G Emmanuel Guindon
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada.
| | - Erica Stone
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Riya Trivedi
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Sophiya Garasia
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Kimia Khoee
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Ontario, Canada
| | - Alexia Olaizola
- Department of Economics, Stanford University, Stanford, CA, USA
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Atkins N, Mukhida K. The relationship between patients’ income and education and their access to pharmacological chronic pain management: A scoping review. Can J Pain 2022; 6:142-170. [PMID: 36092247 PMCID: PMC9450907 DOI: 10.1080/24740527.2022.2104699] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Nicole Atkins
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Karim Mukhida
- Department of Anesthesiology, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Ayodele B, Guo EX, Sweetman A, Guindon GE. Inequity in insurance coverage for prescription drugs in New Brunswick, Canada. CANADIAN JOURNAL OF PUBLIC HEALTH = REVUE CANADIENNE DE SANTE PUBLIQUE 2022; 113:504-518. [PMID: 35488147 PMCID: PMC9263015 DOI: 10.17269/s41997-022-00639-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 03/30/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVES To describe the extent to which New Brunswick residents reported having drug insurance coverage supplementary to Canadian Medicare; to examine associations between socioeconomic and demographic characteristics, health status, language identity, and having reported such coverage; and to document any changes in coverage associated with the introduction of the New Brunswick Drug Plan in 2014. METHODS We used repeated cross-sectional data for New Brunswick from eight cycles of the Canadian Community Health Survey from 2007 to 2017 and undertook logistic regression analysis. RESULTS We found statistically significant, substantial and policy-relevant socioeconomic differences in the reporting of prescription drug insurance coverage among those 25-64 years and those ≥ 65 years of age, and an increasing reliance on private drug insurance over time. We found that individuals in the second decile of household income were particularly vulnerable to reporting neither public nor private drug coverage. The introduction of the New Brunswick Drug Plan in 2014 does not appear to have led to increased public drug coverage; however, from 2014, the decreasing trend in public drug coverage appears to have ceased. Those who reported lower health status usually had lower odds of reporting private drug coverage but higher odds of reporting public drug coverage. Driven by differences in private coverage, we found that relative to anglophones, francophones were less likely to report any drug coverage. CONCLUSION Our findings emphasize the shortcomings of drug insurance systems such as that introduced in New Brunswick and substantiate calls for a universal drug program. New Brunswick's increasing reliance on private drug insurance is of concern and warrants additional research.
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Affiliation(s)
- Busola Ayodele
- Centre for Health Economics and Policy Analysis, McMaster University, CRL Building, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | | | - Arthur Sweetman
- Centre for Health Economics and Policy Analysis, McMaster University, CRL Building, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
- Department of Economics, McMaster University, Hamilton, ON, Canada
| | - G Emmanuel Guindon
- Centre for Health Economics and Policy Analysis, McMaster University, CRL Building, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
- Department of Economics, McMaster University, Hamilton, ON, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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Légaré F, Stacey D, Forest PG, Archambault P, Boland L, Coutu MF, Giguère AMC, LeBlanc A, Lewis KB, Witteman HO. Shared decision-making in Canada: Update on integration of evidence in health decisions and patient-centred care government mandates. ZEITSCHRIFT FUR EVIDENZ, FORTBILDUNG UND QUALITAT IM GESUNDHEITSWESEN 2022; 171:22-29. [PMID: 35606312 DOI: 10.1016/j.zefq.2022.04.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 04/12/2022] [Accepted: 04/13/2022] [Indexed: 06/15/2023]
Abstract
In Canada, government mandates for patient-centred care (PCC) vary across the 10 provinces and three territories. Although basic medical and hospital services are provided for all, health care options for patients also depend on having private insurance. Thus, the current design of the Canadian healthcare system has several implications for PCC and shared decision-making (SDM). Since 2007, this is our fourth update on SDM in Canada. The aim of this paper is to provide an update on the current state of SDM and patient and public involvement in Canada. Overall, we still observed the difficulty of implementing any sort of national strategy partly because of the decentralized nature of the healthcare system. Second, national professional education programs are complicated by licensure and scope of practice variations across jurisdictions. Third, there are variations in the availability of different options covered by universal healthcare. Canada has experienced some favorable development as PCC is now explicitly articulated in the policies of most provinces and territories and there are increased efforts to give patients more access to their electronic health records. However, patient and public engagement (PPE) reform in health programs and governance remains an exception, and continuing centralization of governance structures may reduce their responsiveness to patient priorities. In a 2018 survey, 47.2% of respondents reported that they were not told by their health professional that they had a choice about treatment. Nonetheless, decision aids and decision coaching are increasingly available for health-related decisions and the Ottawa Hospital Research Institute's decision aid inventory has ensured continued leadership in this area. Diverse jurisdictions are starting to embed decision aids into care pathways, with some decision aids being included in clinical practice guidelines. The COVID-19 pandemic may have had a negative impact on SDM by removing decision choices due to emergency public health mandates, but stimulated new research and decision aids. Canada continues to assign health research funding to SDM and PCC, and a program dedicated to patient-oriented research is central to this effort. Guides and frameworks are increasingly available for planning and evaluating PPE. Finally, various initiatives are attempting to involve and empower Indigenous peoples through PPE and SDM.
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Affiliation(s)
- France Légaré
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada; Research Centre of the Centre Hospitalier Universitaire de Québec, Quebec City, Canada.
| | - Dawn Stacey
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Patrick Archambault
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada; Research Centre of the Centre Hospitalier Universitaire de Québec, Quebec City, Canada; Centre de recherche intégrée pour un système apprenant en santé et services sociaux, Centre intégré de santé et services sociaux de Chaudière-Appalaches, Lévis, Canada; Department of Anesthesiology and Intensive Care Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
| | - Laura Boland
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada; Ottawa Hospital Research Institute, Ottawa, Canada
| | - Marie-France Coutu
- Centre for Action in Work Disability Prevention and Rehabilitation affiliated with Hôpital Charles-Lemoyne Research Center, Rehabilitation School, Longueuil Campus - Université de Sherbrooke, Longueuil, Canada
| | - Anik M C Giguère
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada; Office of Education and Continuing Development, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
| | - Annie LeBlanc
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
| | - Krystina B Lewis
- Faculty of Health Sciences, University of Ottawa, Ottawa, Canada; University of Ottawa Heart Institute, Ottawa, Canada
| | - Holly O Witteman
- VITAM - Centre de recherche en santé durable, Centre intégré universitaire de santé et services sociaux (CIUSSS) de la Capitale-Nationale, Quebec City, Canada; Department of Family Medicine and Emergency Medicine, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada; Research Centre of the Centre Hospitalier Universitaire de Québec, Quebec City, Canada; Ottawa Hospital Research Institute, Ottawa, Canada; Office of Education and Continuing Development, Faculty of Medicine, Université Laval, Pavillon Ferdinand-Vandry, Quebec City, Canada
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Islam MK, Kellett P. Provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. Int J Health Plann Manage 2022; 37:2090-2105. [PMID: 35246875 DOI: 10.1002/hpm.3451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 01/10/2022] [Accepted: 02/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Despite spending 11.0% of the total gross domestic product, the quality of healthcare services in Canada has received mixed reviews. We first separately examined provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. Second, we evaluated provincial variations in the impact of not having a regular medical doctor on having unmet healthcare needs among Canadians. METHODS We applied logistic regressions using data from the 2014 and 2017-2018 Canadian Community Health Surveys (CCHS). The total sample size for this study was 120,345 individuals aged 12 years and older: 61,240 from the 2014 CCHS and 59,105 from the 2017-2018 CCHS. RESULTS We found significant provincial variations in not having a regular medical doctor and having unmet healthcare needs among Canadians. People in Quebec and the Territories were more likely not to have a regular medical doctor than their peers in Alberta. People in Quebec and the Territories were also more likely to have unmet healthcare needs than their counterparts in Alberta. Not having a regular medical doctor impacted whether Canadians reported having unmet healthcare needs to varying degrees across provinces. CONCLUSION Findings from this study may contribute to designing province-specific policy interventions and inform efforts that seek to address barriers to having a regular medical doctor and reducing unmet healthcare needs among Canadians.
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Affiliation(s)
- Md Kamrul Islam
- The Prentice Institute for Global Population and Economy, University of Lethbridge, Lethbridge, Alberta, Canada
| | - Peter Kellett
- Faculty of Health Sciences, University of Lethbridge, Lethbridge, Alberta, Canada
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Guindon GE, Fatima T, Garasia S, Khoee K. A systematic umbrella review of the association of prescription drug insurance and cost-sharing with drug use, health services use, and health. BMC Health Serv Res 2022; 22:297. [PMID: 35241088 PMCID: PMC8895849 DOI: 10.1186/s12913-022-07554-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Increasing spending and use of prescription drugs pose an important challenge to governments that seek to expand health insurance coverage to improve population health while controlling public expenditures. Patient cost-sharing such as deductibles and coinsurance is widely used with aim to control healthcare expenditures without adversely affecting health. METHODS We conducted a systematic umbrella review with a quality assessment of included studies to examine the association of prescription drug insurance and cost-sharing with drug use, health services use, and health. We searched five electronic bibliographic databases, hand-searched eight specialty journals and two working paper repositories, and examined references of relevant reviews. At least two reviewers independently screened the articles, extracted the characteristics, methods, and main results, and assessed the quality of each included study. RESULTS We identified 38 reviews. We found consistent evidence that having drug insurance and lower cost-sharing among the insured were associated with increased drug use while the lack or loss of drug insurance and higher drug cost-sharing were associated with decreased drug use. We also found consistent evidence that the poor, the chronically ill, seniors and children were similarly responsive to changes in insurance and cost-sharing. We found that drug insurance and lower drug cost-sharing were associated with lower healthcare services utilization including emergency room visits, hospitalizations, and outpatient visits. We did not find consistent evidence of an association between drug insurance or cost-sharing and health. Lastly, we did not find any evidence that the association between drug insurance or cost-sharing and drug use, health services use or health differed by socioeconomic status, health status, age or sex. CONCLUSIONS Given that the poor or near-poor often report substantially lower drug insurance coverage, universal pharmacare would likely increase drug use among lower-income populations relative to higher-income populations. On net, it is probable that health services use could decrease with universal pharmacare among those who gain drug insurance. Such cross-price effects of extending drug coverage should be included in costing simulations.
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Affiliation(s)
- G Emmanuel Guindon
- Centre for Health Economics and Policy Analysis, McMaster University, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada.
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Department of Economics, McMaster University, Hamilton, ON, Canada.
| | - Tooba Fatima
- Centre for Health Economics and Policy Analysis, McMaster University, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
| | - Sophiya Garasia
- Centre for Health Economics and Policy Analysis, McMaster University, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kimia Khoee
- Centre for Health Economics and Policy Analysis, McMaster University, Room 229, 1280 Main Street West, Hamilton, ON, L8S 4K1, Canada
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Ahmad A, Abbas M, Miregwa B, Holbrook AM. Variability in Prescription Medication Coverage for Children and Youth Across Canada: A Scoping Review. Health Policy 2022; 126:269-279. [DOI: 10.1016/j.healthpol.2022.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 11/04/2022]
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Antonipillai V, Guindon GE, Sweetman A, Baumann A, Wahoush O, Schwartz L. Associations of health services utilization by prescription drug coverage and immigration category in Ontario, Canada. Health Policy 2021; 125:1311-1321. [PMID: 34226053 DOI: 10.1016/j.healthpol.2021.06.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/09/2021] [Accepted: 06/16/2021] [Indexed: 11/15/2022]
Abstract
Canada is the only high-income country with a universal healthcare system that does not provide prescription drug coverage for all its residents. This study examines whether Canadians' prescription drug coverage status is associated with their health services use and how this association differs by gender across non-migrants and three categories of migrants: economic immigrants, family-class immigrants, and refugees. Very few studies have examined differences across these migrant groups, and there is a need to do so as they experience varying health disparities. This study contributes to the prescription drug coverage, migration and health literature by employing an intersectional lens to analyze a sample of Ontario working-aged residents (n=39,792) generated from linking the Canadian Community Health Survey (2005, 2008, 2013, 2014) and Longitudinal Immigrant Database. Predicted probabilities and average marginal effects from multivariable logistic regression models were generated, and interaction effects between prescription drug coverage and immigrant status were examined. The study reveals important differences in the use of health services across prescription drug coverage groups by immigration status. As the general debate about universal pharmacare in Canada is ongoing, this study reveals that drug insurance is positively associated with health services use of most migrants and non-migrants, however, some immigrant women may still experience barriers to access general practitioner services. If pharmacare is introduced, ongoing evaluation is needed to ensure that its implementation produces equitable outcomes for all.
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Affiliation(s)
| | - G Emmanuel Guindon
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
| | - Arthur Sweetman
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada; Economics, McMaster University, Hamilton, Canada
| | - Andrea Baumann
- Global Health, McMaster University, Hamilton, Canada; School of Nursing, McMaster University, Hamilton, Canada
| | - Olive Wahoush
- Global Health, McMaster University, Hamilton, Canada; School of Nursing, McMaster University, Hamilton, Canada
| | - Lisa Schwartz
- Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada; Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, Canada
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