The case for a medicare drug coverage benefit: a critical review of the empirical evidence

A systematic umbrella review of the association of prescription drug insurance and cost-sharing with drug use, health services use, and health

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.

Effectiveness and Safety of Intradetrusor OnabotulinumtoxinA Injection for Neurogenic Detrusor Overactivity and Overactive Bladder Patients in Taiwan-A Phase IV Prospective, Interventional, Multiple-Center Study (Restore Study)

We conducted a phase IV, pre/post multi-center study to evaluate the efficacy and safety of intradetrusor onabotulinumtoxinA injection in patients with neurogenic detrusor overactivity (NDO, n = 119) or overactive bladder (OAB, n = 215). Patients received either 200U (i.e., NDO) and 100U (i.e., OAB) of onabotulinumtoxinA injection into the bladder, respectively. The primary endpoint for all patients was the change in the PPBC questionnaire score at week 4 and week 12 post-treatment compared with baseline. The secondary endpoints were the changes in subjective measures (i.e., questionnaires: NBSS for patients with NDO and OABSS for those with OAB) at week 4 and week 12 post-treatment compared with baseline. Adverse events included symptomatic UTI, de novo AUR, gross hematuria and PVR > 350mL were recorded. The results showed that compared with baseline, PPBC (3.4 versus 2.4 and 2.1, p < 0.001) and NBSS (35.4 versus 20.4 and 18.1, p < 0.001) were significantly improved at 4 weeks and 12 weeks in NDO patients. In addition, compared with baseline, PPBC (3.5 versus 2.3 and 2.0, p < 0.001) and OABSS (9.1 versus 6.2 and 5.7, p < 0.001) were significantly improved at 4 weeks and 12 weeks in OAB patients. Eight (6.7%) had symptomatic UTI and 5 (4.2%) had de novo AUR in NDO patients. Twenty (9.3%) had symptomatic UTI but no de novo AUR in OAB patients. In conclusion, we found that intradetrusor onabotulinumtoxinA injections were safe and improved subjective measures related to NDO or OAB in our cohort.

Variation in the prescription drugs covered by health systems across high-income countries: A review of and recommendations for the academic literature

BACKGROUND

Because not all medicines are equally safe, effective, and affordable, health systems often use formularies to define explicitly which medicines will be included and excluded from coverage.

OBJECTIVE

We sought to synthesize methods and findings from published studies of formulary variation across health systems in high-income countries.

METHODS

We conducted a systematic review of peer-reviewed research papers published from 2000 to 2017, inclusively. Because of the heterogeneous nature of the literature, we used an inductive approach to summarize methods and findings.

RESULTS

Nine studies met our study inclusion criteria. Included studies used a variety of methods for selecting medicines for analysis, for measuring coverage levels, and for measuring concordance between formularies. Studies assessing variations in coverage of all licensed medicines and found lower rates of cross-national coverage variation than studies of coverage for selected specialty drugs and indications. The one study that focused on coverage of high-volume medicines found the most complete and consistent levels of formulary listings across countries.

CONCLUSION

Although published studies contain interesting findings that likely have prompted discussions about their policy implications, the literature can be improved with greater transparency concerning the overarching objective of work in this area and more rigor concerning the selection, analysis, and reporting of data.

Impact of financial burden, resulting from prescription co-payments, on antihypertensive medication adherence in an older publically insured population

Introduction

Medication co-payments represent a financial barrier to antihypertensive medication adherence. The introduction of co-payments for Irish publically insured patients was associated with a 5% reduction in adherence. However there is socioeconomic variability within this population, and the impact may be greater for those on lower income. We evaluated medication-related financial burden of the co-payment in a cohort of Irish publically insured antihypertensive users and tested its association with adherence at 12 months.

Methods

This was a prospective cohort study of community dwelling older (> 65 yrs) adults (n = 1152) from 106 Irish community pharmacies. Participants completed a structured telephone interview at baseline, and a follow-up interview at 12-months, which we linked to pharmacy records. We assessed medication-related financial burden at baseline using a single questionnaire item, and adherence at 12 months via questionnaire and refill-adherence as Proportion of Days Covered (PDC).

Results

A third of participants (30.1%) reported financial burden due to medication costs. In adjusted linear regression models financially burdened participants had significantly lower self-reported adherence (β = − 0.29, 95% CI -0.48 to − 0.11), although this was not evident with PDC (β = − 2.76, 95% CI -5.65 to 0.14).

Conclusion

This co-payment represents a financial barrier to antihypertensive adherence for many older Irish publically insured patients. The negative impact to adherence will potentially increase the risk of adverse outcomes, such as stroke, and increase long-term healthcare costs.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6209-8) contains supplementary material, which is available to authorized users.

[Analysis of economic cost of missed outpatient appointments]

AIM

To estimate the economic costs of missed Outpatient appointments by the Costa del Sol Health Agency (ASCS).

METHOD

An analysis was performed on the costs arising from missed outpatient appointments (first appointment and examinations) of each of the specialities in the Centres belonging to the ASCS. A formula was used to determine the unit cost per appointment and per centre and speciality. This involved the direct imputation of the controllable costs and the indirect imputation of the service costs, together with an estimated cost of re-appointments based on a previous case-control study.

RESULTS

The cost of missed appointments per centre in the Costa del Sol Hospital was €2,475,640, with a failure rate of 14.2% (256,377 appointments). In the Benalmádena High Resolution Hospital it was €515,936, with an absence rate of 12.2% (44,848 appointments), and in the Mijas High Resolution Centre, a cost of €395,342 with an absence rate of the 13.5% (99,536 appointments). The mean extra cost of a re-appointment was €12.95. The specialities with a higher medium cost were Digestive Diseases, Internal Medicine, and Rehabilitation.

CONCLUSIONS

The economic cost of patients not turning up for scheduled appointments in the ASCS was greater than 3 million Euros for a non-attendance rate of the 13.8%, with Mijas High Resolution Centre being the centre that showed the lowest mean unitary cost per medical appointment.

Drug Product Life-Cycle Management as Anticompetitive Behavior: The Case of Memantine

A "product hop" involves the substitution of a new formulation of a prescription drug by a pharmaceutical manufacturer for an old version to forestall generic competition. In 2015, for example, Forest Laboratories, the brand-name drug manufacturer of memantine, an Alzheimer's disease treatment, introduced an extended-release version and tried to restrict patient access to the previous version. Product hops can lead to useful incremental innovation but can also have major public health implications by disrupting patients on stable treatment regimens and increasing costs for patients and payers. This commentary reviews alleged anticompetitive product hopping in the case of memantine, which involved proposed conduct that would have left Alzheimer's disease patients with no effective choice but to transition to memantine XR. Policy solutions that can limit anticompetitive product hops include raising the bar for obtaining patents on new drug product formulations and changing automatic generic substitution laws.

DISCLOSURES

No outside funding supported this research. To support his work at PORTAL in the summer of 2015, Capati was the recipient of the University of New Hampshire School of Law Rudman Center Public Service Fellowship. Kesselheim's research was supported by Greenwall Faculty Scholars program, the Laura and John Arnold Foundation, and the Harvard Program in Therapeutic Science. In 2013, Kesselheim served as an expert on behalf of a class of individual plaintiffs against Warner Chilcott regarding potential antitrust violations Kesselheim was responsible for concept and design of this commentary. Capati took the lead in data collection and analysis, along with Kesselheim. Capati wrote the manuscript, which was revised by primarily by Kesselheim, along with Capati.

The effects of catastrophic drug plan deductibles on older women's use of cardiovascular medicines: a retrospective cohort study

BACKGROUND

In recent years, some provinces have implemented income-based catastrophic drug coverage in an effort to provide universal drug coverage while limiting government liability for the escalating costs of medicines needed for an aging population. We sought to examine the effects of income-based deductibles under British Columbia's Fair PharmaCare system on older patients' use of cardiovascular medicines in 2013, 10 years after the province's policy change.

METHODS

Using linked administrative databases, we studied rates of hypertension and cholesterol medication used by 2 cohorts of older, married women who had different levels of public drug subsidy based solely on their spouses' ages. We compare measures of 2013 medication use by study cohorts using statistical models that controlled for age, general health status, indicators of need for specific drug classes, ethnicity, rural residence and household income.

RESULTS

Among members of our study cohorts, the odds of filling cardiovascular prescriptions in 2013 were influenced by patient age, general health status, drug-specific diagnoses, ethnicity, place of residence and household income. For women with household incomes less than $50 000 (42% of our study population), having preferential public drug coverage by way of spousal age was associated with a 15% increase in the adjusted odds of filling 1 or more prescription for hypertension treatment (adjusted odds ratio [OR] 1.15, 95% confidence interval [CI] 1.06 to 1.24) and a 13% increase in the adjusted odds of filling 1 or more prescription for cholesterol treatments (adjusted OR 1.13, 95% CI 1.06 to 1.21). There were no statistically significant effects on the number of days of therapy purchased per user of these cardiovascular medicines.

INTERPRETATION

We have found that the level of income-based deductibles under catastrophic drug benefi t plans can affect the use of cardiovascular drug treatments, even long after deductibles are put in place. These results add to the body of evidence in support of the idea that public drug coverage design can affect access to necessary medications.

Cost-related nonadherence to prescribed medicines among older Canadians in 2014: a cross-sectional analysis of a telephone survey

BACKGROUND

Canadians receive universal coverage for medically necessary hospital and physician services, but pharmaceutical coverage is incomplete. We sought to assess the effects of cost on access to medicines among older Canadians using data from a large survey conducted in 2014.

METHODS

This is a cross-sectional analysis of data from the Commonwealth Fund's 2014 International Health Policy Survey of Older Adults. Our primary outcome variable was self-reported cost-related nonadherence in the form of either not filling a prescription or skipping doses within the last 12 months because of out-of-pocket costs. We computed sample-weighted estimates of the population prevalence of cost-related nonadherence and conducted logistic regression analyses to determine associated factors.

RESULTS

We estimate that the prevalence of cost-related nonadherence in 2014 among Canadians aged 55 years and older was 8.3% (about 1 in 12). The population prevalence and adjusted odds of cost-related nonadherence was significantly higher among Canadians who were younger, in worse health, poorer or without private health insurance. Regional differences in population prevalence of cost-related nonadherence were not significant. The only provincial or regional difference in the adjusted odds of cost-related nonadherence was that residents of Quebec aged 55-64 years were about half as likely to report nonadherence as similarly aged residents of Ontario, our reference province (adjusted odds ratio 0.49, 95% confidence interval 0.29-0.82).

INTERPRETATION

The financial accessibility of prescription medicines still is a substantial public health issue in Canada that affects 1 in 12 Canadians older than 55 years of age. Older Canadians at greatest risk of cost-related nonadherence to prescribed treatments are those with low incomes and those without private insurance to cover costs not covered by public programs.

Universal prescription drug coverage in Canada: Long-promised yet undelivered

Canada's universal public healthcare system is unique among developed countries insofar as it does not include universal coverage of prescription drugs. Universal, public coverage of prescription drugs has been recommended by major national commissions in Canada dating back to the 1960s. It has not, however, been implemented. In this article, we extend research on the failure of early proposals for universal drug coverage in Canada to explain failures of calls for reform over the past 20 years. We describe the confluence of barriers to reform stemming from Canadian policy institutions, ideas held by federal policy-makers, and electoral incentives for necessary reforms. Though universal "pharmacare" is once again on the policy agenda in Canada, arguably at higher levels of policy discourse than ever before, the frequently recommended option of universal, public coverage of prescription drugs remains unlikely to be implemented without political leadership necessary to overcome these policy barriers.

The anticipatory effects of Medicare Part D on drug utilization

While health care policies are frequently signed into law well before they are implemented, such lags are ignored in most empirical work. This paper demonstrates the importance of implementation lags in the context of Medicare Part D, the prescription drug benefit that took effect two years after it was signed into law. Exploiting the differential responses of chronic and acute drugs to anticipated future prices, I show that individuals reduced drug utilization for chronic but not acute drugs in anticipation of Part D's implementation. Accounting for this anticipatory response substantially reduces the estimated total treatment effect of Part D.

Effects of Prescription Drug User Fees on Drug and Health Services Use and on Health Status in Vulnerable Populations: A Systematic Review of the Evidence

Rising pharmaceutical expenditures have led to the use of cost-sharing measures. The authors undertook a systematic review of the effects of cost sharing on vulnerable populations (the poor and those with chronic illnesses). Virtually every article reviewed supports the view that cost sharing decreases the use of prescription drugs in these populations. Copayments or a cap on the monthly number of subsidized prescriptions lower drug costs for the payer, but any savings may be offset by increases in other health care areas. Cost sharing also leads to patients foregoing essential medications and to a decline in health care status.

Is cost-related non-collection of prescriptions associated with a reduction in health? Findings from a large-scale longitudinal study of New Zealand adults

OBJECTIVE

To investigate whether cost-related non-collection of prescription medication is associated with a decline in health.

SETTINGS

New Zealand Survey of Family, Income and Employment (SoFIE)-Health.

PARTICIPANTS

Data from 17 363 participants with at least two observations in three waves (2004-2005, 2006-2007, 2008-2009) of a panel study were analysed using fixed effects regression modelling.

PRIMARY OUTCOME MEASURES

Self-rated health (SRH), physical health (PCS) and mental health scores (MCS) were the health measures used in this study.

RESULTS

After adjusting for time-varying confounders, non-collection of prescription items was associated with a 0.11 (95% CI 0.07 to 0.15) unit worsening in SRH, a 1.00 (95% CI 0.61 to 1.40) unit decline in PCS and a 1.69 (95% CI 1.19 to 2.18) unit decline in MCS. The interaction of the main exposure with gender was significant for SRH and MCS. Non-collection of prescription items was associated with a decline in SRH of 0.18 (95% CI 0.11 to 0.25) units for males and 0.08 (95% CI 0.03 to 0.13) units for females, and a decrease in MCS of 2.55 (95% CI 1.67 to 3.42) and 1.29 (95% CI 0.70 to 1.89) units for males and females, respectively. The interaction of the main exposure with age was significant for SRH. For respondents aged 15-24 and 25-64 years, non-collection of prescription items was associated with a decline in SRH of 0.12 (95% CI 0.03 to 0.21) and 0.12 (95% CI 0.07 to 0.17) units, respectively, but for respondents aged 65 years and over, non-collection of prescription items had no significant effect on SRH.

CONCLUSION

Our results show that those who do not collect prescription medications because of cost have an increased risk of a subsequent decline in health.

Medicare Part D coverage gap: race, gender, and cost-related medication nonadherence

This study examined whether the Medicare Part D coverage gap directly and indirectly affects the relationship between race, gender, and cost-related nonadherence (CRN). Using a nationally representative sample (N = 1,157), this study found that racial disparities in CRN existed under Medicare Part D. However, reaching the coverage gap mediated differences in CRN between older Blacks and Whites. The coverage gap was associated with CRN and poorer health and lower income were associated with CRN after accounting for coverage gap status. Findings highlight the need to help vulnerable populations avoid CRN and for greater consideration of racial inequities in future policy decisions.

Pharmaceutical policies: effects of cap and co-payment on rational use of medicines

BACKGROUND

Growing expenditures on prescription medicines represent a major challenge to many health systems. Cap and co-payment policies are intended as an incentive to deter unnecessary or marginal utilisation, and to reduce third-party payer expenditures by shifting parts of the financial burden from insurers to patients, thus increasing their financial responsibility for prescription medicines. Direct patient payment policies include caps (maximum numbers of prescriptions or medicines that are reimbursed), fixed co-payments (patients pay a fixed amount per prescription or medicine), co-insurance (patients pay a percentage of the price), ceilings (patients pay the full price or part of the cost up to a ceiling, after which medicines are free or are available at reduced cost) and tier co-payments (differential co-payments usually assigned to generic and brand medicines). This is the first update of the original review.

OBJECTIVES

To determine the effects of cap and co-payment (cost-sharing) policies on use of medicines, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

For this update, we searched the following databases and websites: The Cochrane Central Register of Controlled Trials (CENTRAL) (including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, Cochrane Library; MEDLINE, Ovid; EMBASE, Ovid; IPSA, EBSCO; EconLit, ProQuest; Worldwide Political Science Abstracts, ProQuest; PAIS International, ProQuest; INRUD Bibliography; WHOLIS, WHO; LILACS), VHL; Global Health Library WHO; PubMed, NHL; SCOPUS; SciELO, BIREME; OpenGrey; JOLIS Library Network; OECD Library; World Bank e-Library; World Health Organization, WHO; World Bank Documents & Reports; International Clinical Trials Registry Platform (ICTRP), WHO; ClinicalTrials.gov, NIH. We searched all databases during January and February 2013, apart from SciELO, which we searched in January 2012, and ICTRP and ClinicalTrials.gov, which we searched in March 2014.

SELECTION CRITERIA

We defined policies in this review as laws, rules or financial or administrative orders made by governments, non-government organisations or private insurers. We included randomised controlled trials, non-randomised controlled trials, interrupted time series studies, repeated measures studies and controlled before-after studies of cap or co-payment policies for a large jurisdiction or system of care. To be included, a study had to include an objective measure of at least one of the following outcomes: medicine use, healthcare utilisation, health outcomes or costs (expenditures).

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study limitations. We reanalysed time series data for studies with sufficient data, if appropriate analyses were not reported.

MAIN RESULTS

We included 32 full-text articles (17 new) reporting evaluations of 39 different interventions (one study - Newhouse 1993 - comprises five papers). We excluded from this update eight controlled before-after studies included in the previous version of this review, because they included only one site in their intervention or control groups. Five papers evaluated caps, and six evaluated a cap with co-insurance and a ceiling. Six evaluated fixed co-payment, two evaluated tiered fixed co-payment, 10 evaluated a ceiling with fixed co-payment and 10 evaluated a ceiling with co-insurance. Only one evaluation was a randomised trial. The certainty of the evidence was found to be generally low to very low.Increasing the amount of money that people pay for medicines may reduce insurers' medicine expenditures and may reduce patients' medicine use. This may include reductions in the use of life-sustaining medicines as well as medicines that are important in treating chronic conditions and medicines for asymptomatic conditions. These types of interventions may lead to small decreases in or uncertain effects on healthcare utilisation. We found no studies that reliably reported the effects of these types of interventions on health outcomes.

AUTHORS' CONCLUSIONS

The diversity of interventions and outcomes addressed across studies and differences in settings, populations and comparisons made it difficult to summarise results across studies. Cap and co-payment polices may reduce the use of medicines and reduce medicine expenditures for health insurers. However, they may also reduce the use of life-sustaining medicines or medicines that are important in treating chronic, including symptomatic, conditions and, consequently, could increase the use of healthcare services. Fixed co-payment with a ceiling and tiered fixed co-payment may be less likely to reduce the use of essential medicines or to increase the use of healthcare services.

Persistent medication affordability problems among disabled Medicare beneficiaries after Part D, 2006-2011

BACKGROUND

Disabled Americans who qualify for Medicare coverage typically have multiple chronic conditions, are highly dependent on effective drug therapy, and have limited financial resources, putting them at risk for cost-related medication nonadherence (CRN). Since 2006, the Part D benefit has helped Medicare beneficiaries afford medications.

OBJECTIVE

To investigate recent national trends in medication affordability among this vulnerable population, stratified by morbidity burden.

DESIGN AND SUBJECTS

We estimated annual rates of medication affordability among nonelderly disabled participants in a nationally representative survey (2006-2011, n=14,091 person-years) using multivariate logistic regression analyses.

MEASURE

Survey-reported CRN and spending less on other basic needs to afford medicines.

RESULTS

In the 6 years following Part D implementation, the proportion of disabled Medicare beneficiaries reporting CRN ranged from 31.6% to 35.6%, while the reported prevalence of spending less on other basic needs to afford medicines ranged from 17.7% to 21.8%. Across study years, those with multiple chronic conditions had consistently worse affordability problems. In 2011, the prevalence of CRN was 37.3% among disabled beneficiaries with ≥ 3 morbidities as compared with 28.1% among those with fewer morbidities; for spending less on basic needs, the prevalence was 25.4% versus 15.7%, respectively. There were no statistically detectable changes in either measure when comparing 2011 with 2007.

CONCLUSIONS

Disabled Medicare beneficiaries continue to struggle to afford prescription medications. There is an urgent need for focused policy attention on this vulnerable population, which has inadequate financial access to drug treatments, despite having drug coverage under Medicare Part D.

The effect of copayments for prescriptions on adherence to prescription medicines in publicly insured populations; a systematic review and meta-analysis

Introduction

Copayments are intended to decrease third party expenditure on pharmaceuticals, particularly those regarded as less essential. However, copayments are associated with decreased use of all medicines. Publicly insured populations encompass some vulnerable patient groups such as older individuals and low income groups, who may be especially susceptible to medication non-adherence when required to pay. Non-adherence has potential consequences of increased morbidity and costs elsewhere in the system.

Objective

To quantify the risk of non-adherence to prescribed medicines in publicly insured populations exposed to copayments.

Methods

The population of interest consisted of cohorts who received public health insurance. The intervention was the introduction of, or an increase, in copayment. The outcome was non-adherence to medications, evaluated using objective measures. Eight electronic databases and the grey literature were systematically searched for relevant articles, along with hand searches of references in review articles and the included studies. Studies were quality appraised using modified EPOC and EHPPH checklists. A random effects model was used to generate the meta-analysis in RevMan v5.1. Statistical heterogeneity was assessed using the I² test; p>0.1 indicated a lack of heterogeneity.

Results

Seven out of 41 studies met the inclusion criteria. Five studies contributed more than 1 result to the meta-analysis. The meta-analysis included 199, 996 people overall; 74, 236 people in the copayment group and 125,760 people in the non-copayment group. Average age was 71.75years. In the copayment group, (verses the non-copayment group), the odds ratio for non-adherence was 1.11 (95% CI 1.09–1.14; P = <0.00001). An acceptable level of heterogeneity at I² = 7%, (p = 0.37) was observed.

Conclusion

This meta-analysis showed an 11% increased odds of non-adherence to medicines in publicly insured populations where copayments for medicines are necessary. Policy-makers should be wary of potential negative clinical outcomes resulting from non-adherence, and also possible knock-on economic repercussions.

UPTAKE AND DIFFUSION OF PHARMACEUTICAL INNOVATIONS IN HEALTH SYSTEMS

Multiple interacting factors influence the uptake and diffusion of medicines which are critical to improving health. However, there is a gap in our knowledge on how regulatory policies and other national health systems attributes combine to impact on the utilisation of innovative drugs, and health system goals and objectives.

Our review demonstrates that strong regulation adversely affects, access to innovation, reduces incentives for research-based firms to develop innovative products and leads to short- and long-term welfare losses. Short-term efficiency gains from reducing pharmaceutical expenditures may actually increase total healthcare costs, reduce user choice, and in some cases, adversely affect health outcomes.

Decision makers need to adopt a holistic approach to policy making, and consider potential impact of regulations on the uptake and diffusion of innovations, innovation systems and health system goals.

Registration for public drug benefits across areas of differing ethnic composition in British Columbia, Canada

Background

In 2003, the government of British Columbia, Canada introduced a universal drug benefit plan to cover drug costs that are high relative to household income. Residents were required to register in order to be eligible for the income-based benefits. Given past research suggesting that registration processes may pose an access barrier to certain subpopulations, we aimed to determine whether registration rates varied across small geographic areas that differed in ethnic composition.

Methods

Using linked population-based administrative databases and census data, we conducted multivariate logistic regression analyses to determine whether the probability of registration for the public drug plan varied across areas of differing ethnic composition, controlling for household-level predisposing, enabling and needs factors.

Results

The adjusted odds of registration did not differ across regions characterized by high concentrations (greater than 30%) of residents identifying as North American, British, French or other European. Households located in areas with concentrations of residents identifying as an Asian ethnicity had the highest odds of program registration: Chinese (OR = 1.21, CI: 1.19-1.23) and South Asian (OR = 1.19, CI: 1.16-1.22). Despite this positive finding, households residing in areas with relatively high concentrations of recent immigrants had slightly lower adjusted odds of registering for the program (OR = 0.97, CI: 0.95-0.98).

Conclusions

This study identified ethnic variation in registration for a new public drug benefit program in British Columbia. However, unlike previous studies, the variation observed did not indicate that areas with high concentrations of certain ethnicities experienced disadvantages. Potential explanations are discussed.

Lessons learned: who didn't enroll in Medicare drug coverage in 2006, and why?

The law that created Medicare's prescription drug benefit, Medicare Part D, also established extra help for low-income seniors in the form of a subsidy. This study, the first in-depth analysis of Part D enrollment among Medicare beneficiaries without prior drug coverage, finds that 63 percent of all eligible seniors and 69 percent of low-income beneficiaries were enrolled in Part D in 2006. However, only 29 percent of low-income beneficiaries were enrolled in the subsidy program, leaving millions without coverage. Many reported that premiums were too costly, enrollment too difficult, and information too hard to obtain for enrollment. Additionally, provisions of the recently enacted Patient Protection and Affordable Care Act may have the perverse impact of reducing enrollment in Part D for certain beneficiaries. Our findings emphasize the need to expand eligibility and improve policies to foster enrollment.

Systematic review on quality control for drug management programs: is quality reported in the literature?

BACKGROUND

Maintaining quality of care while managing limited healthcare resources is an ongoing challenge in healthcare. The objective of this study was to evaluate how the impact of drug management programs is reported in the literature and to identify potentially existing quality standards.

METHODS

This analysis relates to the published research on the impact of drug management on economic, clinical, or humanistic outcomes in managed care, indemnity insurance, VA, or Medicaid in the USA published between 1996 and 2007. Included articles were systematically analyzed for study objective, study endpoints, and drug management type. They were further categorized by drug management tool, primary objective, and study endpoints.

RESULTS

None of the 76 included publications assessed the overall quality of drug management tools. The impact of 9 different drug management tools used alone or in combination was studied in pharmacy claims, medical claims, electronic medical records or survey data from either patient, plan or provider perspective using an average of 2.1 of 11 possible endpoints. A total of 68% of the studies reported the impact on plan focused endpoints, while the clinical, the patient or the provider perspective were studied to a much lower degree (45%, 42% and 12% of the studies). Health outcomes were only accounted for in 9.2% of the studies.

CONCLUSION

Comprehensive assessment of quality considering plan, patient and clinical outcomes is not yet applied. There is no defined quality standard. Benchmarks including health outcomes should be determined and used to improve the overall clinical and economic effectiveness of drug management programs.

Implementation of the Medicare Part D prescription drug benefit is associated with antiretroviral therapy interruptions

Antiretroviral (ARV) treatment interruptions are associated with virologic rebound, drug resistance, and increased morbidity and mortality. The Medicare Part D prescription drug benefit, implemented on January 1st, 2006, increased consumer cost-sharing. Consumer cost-sharing is associated with decreased access to medications and adverse clinical outcomes. We assessed the association of Part D implementation with treatment interruptions by studying 125 HIV-infected homeless and marginally housed individuals with drug coverage receiving ARV therapy. Thirty-five percent of respondents reported Medicare coverage and 11% reported ARV interruptions. The odds of ARV interruptions were six times higher among those with Part D coverage and remained significant after adjustment. The majority of Part D-covered respondents reporting ARV interruptions cited increased cost as their primary barrier. Directed interventions to monitor the long-term effects of increased cost burden on interruptions and clinical outcomes and to reduce cost burden are necessary to avoid preventable increases in morbidity and mortality.

Coping with prescription drug cost sharing: knowledge, adherence, and financial burden

OBJECTIVE

Assess patient knowledge of and response to drug cost sharing.

STUDY SETTING

Adult members of a large prepaid, integrated delivery system.

STUDY DESIGN/DATA COLLECTION

Telephone interviews with 932 participants (72 percent response rate) who reported knowledge of the structures and amounts of their prescription drug cost sharing. Participants reported cost-related changes in their drug adherence, any financial burden, and other cost-coping behaviors. Actual cost sharing amounts came from administrative databases.

PRINCIPAL FINDINGS

Overall, 27 percent of patients knew all of their drug cost sharing structures and amounts. After adjustment for individual characteristics, additional patient cost sharing structures (tiers and caps), and higher copayment amounts were associated with reporting decreased adherence, financial burden, or other cost-coping behaviors.

CONCLUSIONS

Patient knowledge of their drug benefits is limited, especially for more complex cost sharing structures. Patients also report a range of responses to greater cost sharing, including decreasing adherence.

What impact do prescription drug charges have on efficiency and equity? Evidence from high-income countries

As pharmaceutical expenditure continues to rise, third-party payers in most high-income countries have increasingly shifted the burden of payment for prescription drugs to patients. A large body of literature has examined the relationship between prescription charges and outcomes such as expenditure, use, and health, but few reviews explicitly link cost sharing for prescription drugs to efficiency and equity. This article reviews 173 studies from 15 high-income countries and discusses their implications for important issues sometimes ignored in the literature; in particular, the extent to which prescription charges contain health care costs and enhance efficiency without lowering equity of access to care.

Cost-related medication nonadherence and spending on basic needs following implementation of Medicare Part D

CONTEXT

Cost-related medication nonadherence (CRN) has been a persistent problem for individuals who are elderly and disabled in the United States. The impact of Medicare prescription drug coverage (Part D) on CRN is unknown.

OBJECTIVE

To estimate changes in CRN and forgoing basic needs to pay for drugs following Part D implementation.

DESIGN, SETTING, AND PARTICIPANTS

In a population-level study design, changes in study outcomes between 2005 and 2006 before and after Medicare Part D implementation were compared with historical changes between 2004 and 2005. The community-dwelling sample of the nationally representative Medicare Current Beneficiary Survey (unweighted unique n = 24,234; response rate, 72.3%) was used, and logistic regression analyses were controlled for demographic characteristics, health status, and historical trends.

MAIN OUTCOME MEASURES

Self-reports of CRN (skipping or reducing doses, not obtaining prescriptions) and spending less on basic needs to afford medicines.

RESULTS

The unadjusted, weighted prevalence of CRN was 15.2% in 2004, 14.1% in 2005, and 11.5% after Part D implementation in 2006. The prevalence of spending less on basic needs was 10.6% in 2004, 11.1% in 2005, and 7.6% in 2006. Adjusted analyses comparing 2006 with 2005 and controlling for historical changes (2005 vs 2004) demonstrated significant decreases in the odds of CRN (ratio of odds ratios [ORs], 0.85; 95% confidence interval [CI], 0.74-0.98; P = .03) and spending less on basic needs (ratio of ORs, 0.59; 95% CI, 0.48-0.72; P < .001). No significant changes in CRN were observed among beneficiaries with fair to poor health (ratio of ORs, 1.00; 95% CI, 0.82-1.21; P = .97), despite high baseline CRN prevalence for this group (22.2% in 2005) and significant decreases among beneficiaries with good to excellent health (ratio of ORs, 0.77; 95% CI, 0.63-0.95; P = .02). However, significant reductions in spending less on basic needs were observed in both groups (fair to poor health: ratio of ORs, 0.60; 95% CI, 0.47-0.75; P < .001; and good to excellent health: ratio of ORs, 0.57; 95% CI, 0.44-0.75; P < .001).

CONCLUSIONS

In this survey population, there was evidence for a small but significant overall decrease in CRN and forgoing basic needs following Part D implementation. However, no net decrease in CRN after Part D was observed among the sickest beneficiaries, who continued to experience higher rates of CRN.

Pharmaceutical policies: effects of cap and co-payment on rational drug use

BACKGROUND

Growing expenditures on prescription drugs represent a major challenge to many health systems. Cap and co-payment (direct cost-share) policies are intended as an incentive to deter unnecessary or marginal utilisation, and to reduce third-party payer expenditures by shifting parts of the financial burden from the insurer to patients, thus increasing their financial responsibility for prescription drugs. Direct patient drug payment policies include caps (maximum number of prescriptions or drugs that are reimbursed), fixed co-payments (patients pay a fixed amount per prescription or drug), coinsurance (patients pay a percent of the price), ceilings (patients pay the full price or part of the cost up to a ceiling, after which drugs are free or available at reduced cost), and tier co-payments (differential co-payments usually assigned to generic and brand drugs).

OBJECTIVES

To determine the effects of cap and co-payment (cost-sharing) policies on drug use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH STRATEGY

We searched the following databases and web sites: Effective Practice and Organisation of Care Group Register (date of last search: 6 September 07), Cochrane Central Register of Controlled Trials (27 August 07), MEDLINE (29 August 07), EMBASE (29 August 07), NHS EED (27 August 07), ISI Web of Science (09 January 07), CSA Worldwide Political Science Abstracts (21 October 03), EconLit (23 October 03), SIGLE (12 November 03), INRUD (21 November 03), PAIS International (23 March 04), International Political Science Abstracts (09 January 04), PubMed (25 February 04), NTIS (03 March 04), IPA (22 April 04), OECD Publications & Documents (30 August 05), SourceOECD (30 August 05), World Bank Documents & Reports (30 August 05), World Bank e-Library (04 May 05), JOLIS (22 February 06), Global Jolis (22 February 06), WHOLIS(22 February 06), WHO web site browsed (25 August 05).

SELECTION CRITERIA

We defined policies in this review as laws, rules, or financial or administrative orders made by governments, non-government organisations or private insurers. We included randomised controlled trials, non-randomised controlled trials, interrupted time series analyses, repeated measures studies and controlled before-after studies of cap or co-payment policies for a large jurisdiction or system of care. To be included, a study had to include an objective measure of at least one of the following outcomes: drug use, healthcare utilisation, health outcomes or costs (expenditures).

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed study limitations. We undertook quantitative analysis of time series data for studies with sufficient data.

MAIN RESULTS

We included 30 evaluations (in 21 studies). Of these, 11 evaluated fixed co-payment, six evaluated coinsurance with a ceiling, four evaluated caps, three evaluated fixed co-payment with a ceiling, three evaluated tier co-payment, one evaluated ceiling, one evaluated fixed co-payment and coinsurance with a ceiling, and one evaluated a fixed co-payment with a cap. Most of the included evaluations were observational studies and the quality of the evidence was found to be generally low to moderate. Introducing or increasing direct co-payments reduced drug use and saved plan drug expenditures across studies. Patients responded through drug discontinuation or by cost-sharing. Investigators found reductions for life-sustaining drugs or drugs that are important in treating chronic conditions as well as other drugs. Few studies reported on the effects on health and healthcare utilisation. One study found adverse effects on health through increased healthcare utilisation when a cap was introduced in a vulnerable population. No statistically significant change in use of healthcare services was found in other studies when a cap was introduced on a drug considered over-prescribed in a vulnerable population, or following a shift from a two-tier to a three-tier system with increased co-payments for tier-1 drugs in a general population.

AUTHORS' CONCLUSIONS

We found a diversity of cap and co-payment policies. Poor reporting of the intensity of interventions and differences in setting, populations and interventions made it difficult to make comparisons across studies. Cap and co-payment polices can reduce drug use and save plan drug expenditures. However, although insufficient data on health outcomes were available, substantial reductions in the use of life-sustaining drugs or drugs that are important in treating chronic conditions may have adverse effects on health, and as a result increase the use of healthcare services and overall expenditures. Direct payments are less likely to cause harm if only non-essential drugs are included or exemptions are built in to ensure that patients receive needed medical care.

The influence of prescription drug insurance on psychotropic and non-psychotropic drug utilization in Canada

Using 2002 Canadian Community Health Survey data, this paper examines the effect of public and private prescription drug insurance on the utilization of psychotropic and non-psychotropic drugs. It is found that prescription drug utilization is characterized by two stochastic regimes requiring use of latent class modelling framework. In many instances, results differ for the classes of high and low users of prescription drugs. After accounting for the unobserved individual heterogeneity and a number of socio-demographic factors, health status, and province fixed effects, we find that having prescription drug insurance (public or private) increases the expected number of non-psychotropic medications for both low and high users. Public insurance affects psychotropic drug utilization positively for the low-user group only. The statistical insignificance of insurance for the high-user psychotropic drugs or lower magnitude of insurance coefficients on high-user non-psychotropic drugs seems to stem from high inelastic demand for prescription drugs in the concerned groups. In addition, we find that age, self-reported health status, and long-term mental and physical health problem diagnosed by a health professional are important determinants of prescription drug utilization for both classes of users.

Race/ethnicity and nonadherence to prescription medications among seniors: results of a national study

BACKGROUND

Nonadherence to prescription drugs results in poorer control of chronic health conditions. Because of significant racial/ethnic disparities in the control of many chronic diseases, differences in the rates of and reasons for medication nonadherence should be studied.

OBJECTIVES

1) To determine whether rates of and reasons for medication nonadherence vary by race/ethnicity among seniors; and 2) to evaluate whether any association between race/ethnicity and nonadherence is moderated by prescription coverage and income.

DESIGN/SETTING

Cross-sectional national survey, 2003.

PATIENTS

Medicare beneficiaries > or = 65 years of age, who reported their race/ethnicity as white, black, or Hispanic, and who reported taking at least 1 medication (n = 14,829).

MAIN OUTCOME MEASURES

Self-reported nonadherence (caused by cost, self-assessed need, or experiences/side effects) during the last 12 months.

RESULTS

Blacks and Hispanics were more likely than whites to report cost-related nonadherence (35.1%, 36.5%, and 26.7%, respectively, p < .001). There were no racial/ethnic differences in nonadherence caused by experiences or self-assessed need. In analyses controlling for age, gender, number of chronic conditions and medications, education, and presence and type of prescription drug coverage, blacks (odds ratio [OR] 1.38; 95% confidence interval [CI] 1.08-1.78) and Hispanics (1.35; 1.02-1.78) remained more likely to report cost-related nonadherence compared to whites. When income was added to the model, the relationship between cost-related nonadherence and race/ethnicity was no longer statistically significant (p = .12).

CONCLUSIONS

Racial/ethnic disparities in medication nonadherence exist among seniors, and are related to cost concerns, and not to differences in experiences or self-assessed need. Considering the importance of medication adherence in controlling chronic diseases, affordability of prescriptions should be explicitly addressed to reduce racial/ethnic disparities.

Socioeconomic status, access to health care, and outcomes after acute myocardial infarction in Canada's universal health care system

BACKGROUND

There is a debate as to whether universal drug coverage confers similar access to care at all socioeconomic status (SES) levels. Experiences in Canada may bring light to questions raised regarding access.

OBJECTIVE

To assess associations between SES and access to cardiac care and outcomes in Canada's universal health care system.

DESIGN, SETTING, AND PATIENTS

All patients admitted to acute care hospitals in Quebec (QC), Ontario (ON), and British Columbia (BC), between 1996 and either 2000 (QC) or 2001 (ON, BC) with acute myocardial infarction, were identified using provincial government administrative databases (n = 145,882).

MEASUREMENTS

Variables representing SES grouped at the census area level were examined in association with use of cardiac medications and procedures, survival, and readmission, while adjusting for individual-level variables. A Bayesian hierarchical logistic regression model was used to account for the nested structure of the data.

RESULTS

Despite provincial variations in SES and drug reimbursement policies, there were generally no associations between the SES variables and access to cardiac medications or invasive cardiac procedures. The few exceptions were not consistent across SES indicators and/or provinces. Similarly, the only observed effect of SES on clinical outcomes was in BC, where there was increased 1-year mortality among patients living in less-affluent regions (adjusted odds ratios per standard deviation change in proportion of low-income households, 95% Bayesian credible intervals, QC: 1.09, 0.96-1.25; ON: 1.02, 0.95-1.08; and BC: 1.18, 1.09-1.28).

CONCLUSIONS

These results suggest that intermediary factors other than SES, such as cardiovascular risk factors, likely account for observed "wealth-health" gradients in Canada. Implementation of a universal drug coverage policy could decrease socioeconomic disparities in access to health care.

A cross-national study of prescription nonadherence due to cost: data from the Joint Canada-United States Survey of Health

BACKGROUND

In Canada and the United States, patients who have difficulty paying for prescribed medications are less likely to obtain them and may experience increased risks for morbidity and mortality and/or increased health care costs due to nonadherence. As prescription drug costs have risen, the ability to pay for medications has emerged as a critical public health issue.

OBJECTIVES

The objectives of this study were to estimate the rates of cost-associated nonadherence in Canada and the United States, and to identify factors that predict cost-associated nonadherence in both countries.

METHODS

This original analysis used data from the 2002/2003 Joint Canada-US Survey of Health, a household phone survey jointly conducted by Statistics Canada (Ottawa, Ontario, Canada) and the US National Center for Health Statistics (Hyattsville, Maryland). The sample included 3505 adults in Canada and 5183 adults in the United States. Weighted group comparisons and logistic regression analyses were used to identify population factors predictive of cost-associated prescription nonadherence.

RESULTS

Residents of Canada were much less likely than residents of the United States to report cost-associated nonadherence (5.1% vs 9.9%; P < 0.001). Americans without health insurance (28.2%) and Americans and Canadians without prescription-drug coverage (16.2%) were significantly more likely than those with insurance (6.2%) to report cost-associated nonadherence (P < 0.001). In addition to country of residence and insurance coverage, significant risk factors predictive of nonadherence were young age, poor health, chronic pain, and low household income.

CONCLUSIONS

The results of this analysis suggest that people with low incomes and inadequate insurance, as well as those with poor health and/or chronic symptoms, are more likely to report failing to fill a prescription due to cost. The overall rate of cost-associated nonadherence was significantly higher in the United States than in Canada, even when other person-level factors were controlled for, including health insurance and prescription-drug coverage.

Falling into the Doughnut Hole: Drug Spending among Beneficiaries with End-Stage Renal Disease under Medicare Part D Plans

The Medicare Part D prescription drug benefit may facilitate provision of medications by subsidizing drug costs. However, beneficiaries with higher drug utilization may face higher out-of-pocket (OOP) costs under the benefit's "doughnut hole" provisions that substantially increase beneficiary cost-sharing. The Medicare Current Beneficiary Survey Cost and Use data for 1997 through 2001 were used to estimate the impact of the standard Part D benefit on drug expenditures. The sample consisted of adults who were not dually enrolled in Medicaid (41,617 without ESRD, 256 with ESRD). Outcomes were annual total and OOP drug spending projected to 2006, as well as estimates of individual spending changes under Part D. In 2006, ESRD beneficiaries will have mean annual total and OOP expenditures that are approximately twice that of their Medicare peers. The overall impact of Part D on OOP expenditures is similar among all beneficiaries; however, many individuals with employer-sponsored coverage and those with higher costs (especially those with ESRD) may face cost increases with significant monthly variability as a result of reaching the "doughnut hole," a no-coverage gap in the standard benefit. Therefore, ESRD beneficiaries face substantial total and OOP annual expenditures for medications, causing most to reach the Part D benefit gap. Higher OOP costs may lead to reductions in spending and medication use with subsequent treatment gaps that may lead to increased use of medical services. As the new legislation takes effect, policy makers who are considering modifications in the program may benefit from further research to monitor patterns and gaps in coverage, medication use and spending, and hospitalization and survival trends.

Patient strategies to cope with high prescription medication costs: who is cutting back on necessities, increasing debt, or underusing medications?

Many chronically ill adults in the United States face high prescription medication costs, yet little is known about the strategies patients adopt to cope with these costs. Through a national survey of 4,055 adults taking prescription medications for one of five chronic diseases, we compared whether respondents cut back on necessities such as food or heat to pay for medications, increased debt, or underused medications because of cost. We also examined the sociodemographic and clinical correlates and differential use by different sub-groups of these three strategies. Overall, 31% of respondents reported pursuing at least one of the strategies over the prior 12 months. Twenty-two percent had cut back on necessities, 16% had increased their debt burden, and 18% had underused prescription drugs. Among patients who underused their medication, 67% also had cut necessities or increased debt. Although we found significant differences in the way patients with varying socio-demographic characteristics responded to medication cost pressures, use of all these strategies was especially common among patients who were low-income, in poor health, and taking multiple medications.

A conceptually based approach to understanding chronically ill patients' responses to medication cost pressures

Prescription medications enhance the well-being of most chronically ill patients. Many individuals, however, struggle with how to pay for their treatments and as a result experience problems with self-care and health maintenance. Although studies have documented that high out-of-pocket costs are associated with medication non-adherence, little research on prescription cost sharing has been theoretically grounded in knowledge of the more general determinants of patients' self-management behaviors and chronic disease outcomes. We present a conceptual framework for understanding the influence of patient, medication, clinician, and health system factors on individuals' responses to medication costs. We review what is known about how these factors influence medication adherence, identify possible strategies through which clinicians, health systems, and policy-makers may assist patients burdened by their medication costs, and highlight areas in need of further research. Although medication costs represent a burden to chronically ill patients worldwide, most patients report using their medication as prescribed despite the costs, and others report cost-related underuse despite an apparent ability to afford those treatments. The cost-adherence relationship is modified by contextual factors, including patients' characteristics (e.g., age, ethnicity, and attitudes toward medications), the type of medications they are using (e.g., the complexity of dosing and the drug's clinical target), clinician factors (e.g., choice of first-line agent and communication about medication costs), and health system factors (e.g., efforts to influence clinicians' prescribing and to help patients apply for financial assistance programs). Understanding these relationships will enable clinicians and policy-makers to better design pharmacy benefits and assist patients in taking their medication as prescribed. The next generation of studies examining the consequences of prescription drug costs should expand our knowledge of the ways in which these co-factors influence patients' responses to medication cost pressures.

The health effects of restricting prescription medication use because of cost

BACKGROUND

High out-of-pocket expenditures for prescription medications could lead people with chronic illnesses to restrict their use of these medications. Whether adults experience adverse health outcomes after having restricted medication use because of cost is not known.

METHODS

We analyzed data from 2 prospective cohort studies of adults who reported regularly taking prescription medications using 2 waves of the Health and Retirement Study (HRS), a national survey of adults aged 51 to 61 in 1992, and the Asset and Health Dynamics Among the Oldest Old (AHEAD) Study, a national survey of adults aged 70 or older in 1993 (n = 7991). We used multivariable logistic and Poisson regression models to assess the independent effect on health outcomes over 2 to 3 years of follow up of reporting in 1995-1996 having taken less medicine than prescribed because of cost during the prior 2 years. After adjusting for differences in sociodemographic characteristics, health status, smoking, alcohol consumption, body mass index (BMI), and comorbid chronic conditions, we determined the risk of a significant decline in overall health among respondents in good to excellent health at baseline and of developing new disease-related adverse outcomes among respondents with cardiovascular disease, diabetes, arthritis, and depression.

RESULTS

In adjusted analyses, 32.1% of those who had restricted medications because of cost reported a significant decline in their health status compared with 21.2% of those who had not (adjusted odds ratio [AOR], 1.76; confidence interval [CI], 1.27-2.44). Respondents with cardiovascular disease who restricted medications reported higher rates of angina (11.9% vs. 8.2%; AOR, 1.50; CI, 1.09-2.07) and experienced higher rates of nonfatal heart attacks or strokes (7.8% vs. 5.3%; AOR, 1.51; CI, 1.02-2.25). After adjusting for potential confounders, we found no differences in disease-specific complications among respondents with arthritis and diabetes, and increased rates of depression only among the older cohort.

CONCLUSIONS

Cost-related medication restriction among middle-aged and elderly Americans is associated with an increased risk of a subsequent decline in their self-reported health status, and among those with preexisting cardiovascular disease with higher rates of angina and nonfatal heart attacks or strokes. Such cost-related medication restriction could be a mechanism for worse health outcomes among low-income and other vulnerable populations who lack adequate insurance coverage.

Clinician identification of chronically ill patients who have problems paying for prescription medications

PURPOSE

Little is known about whether health care providers are effectively identifying patients who have difficulty covering the costs of out-of-pocket prescription medications. We examined whether and how providers are identifying chronically ill adults who have potential problems paying for prescription medications.

METHODS

We conducted a cross-sectional survey of a national sample of 4050 adults aged 50 years or older who use prescription medications for at least one of five chronic health conditions. The primary outcome measure was patient report of being asked by a doctor or nurse in the prior 12 months whether the patient could afford the prescribed medication. The measures of prescription cost burden were cost-related underuse of medications, cutting back on other necessities to pay for medications, and worries about medication costs. We adjusted for patient income, education, race/ethnicity, age, sex, health status, number of prescribed medications, pharmacy benefits, frequency of outpatient visits, having a regular health care provider, and sampling weights.

RESULTS

In the weighted analyses, 16% (547/4050) of respondents reported that they had been asked about potential problems paying for a prescribed medication. Only 360 (24%) of the 1499 respondents who reported one or more burdens from out-of-pocket medication costs reported being asked this question. After adjusting for potential confounders, patients who had cut back on medication use or other necessities to cover payments were no more likely than other patients to be asked about the ability to pay for prescription medications. Concerns about medication costs, being a racial/ethnic minority, taking seven or more prescription medications, and having no prescription coverage were independently associated with a greater likelihood of being asked about possible problems with prescription costs.

CONCLUSION

Few chronically ill patients who are at risk of or experiencing problems related to prescription medication costs report that their clinicians had asked them about possible medication payment difficulties.

Outcome of liver transplantation in adult recipients: influence of neighborhood income, education, and insurance

Poor socioeconomic status (SES) may be associated with lower survival after liver transplantation. In a previous study, we showed that African-American race was an independent predictor of poor survival, and one of the major criticisms of our study was that we had not adjusted the survival for SES as a confounding variable. The objective of the present study was to determine the posttransplant outcome of adult liver transplant recipients based on neighborhood income, education, and insurance using the United Network for Organ Sharing (UNOS) database from 1987 to 2001. Patients (n = 29,481) were divided into 5 groups based on median income as determined by zip code: <30,000 dollars, 30,001-40,000 dollars, 40,001-50,000 dollars, 50,001-60,000 dollars, and >60,000 dollars). Patients (n = 14,814) were divided into 4 groups based on level of education: higher than bachelor's degree; college attendance or technical school; high school education (grades 9-12); less than high school education. Insurance payer status (n = 23,440) was divided into Medicaid, Medicare, government agency, HMO/PPO, and private. Cox regression analysis was used to adjust the survival for other known independent predictors such as age, race, UNOS status, diagnosis, and creatinine. Results showed that neighborhood income had no effect on graft or patient survival either in the entire cohort or within different racial groups. Education had only marginal influence on the outcome; survival was lower in those with a high school education than in those with graduate education. Patients with Medicaid and Medicare had lower survival when compared to those with private insurance. African-Americans had a lower 5-year survival when compared to white Americans after adjusting for SES and other confounding variables. In conclusion, neighborhood income does not influence the outcome of liver transplantation. Education had minimal influence, but patients with Medicare and Medicaid had lower survival compared to those with private insurance.

Problems paying out-of-pocket medication costs among older adults with diabetes

OBJECTIVE

To identify problems faced by older adults with diabetes due to out-of-pocket medication costs.

RESEARCH DESIGN AND METHODS

In this cross-sectional national survey of 875 adults with diabetes treated with hypoglycemic medication, respondents reported whether they had underused prescription medications due to cost pressures or had experienced other financial problems associated with medication costs such as forgoing basic necessities. Respondents also described their interactions with clinicians about medication costs.

RESULTS

A total of 19% of respondents reported cutting back on medication use in the prior year due to cost, 11% reported cutting back on their diabetes medications, and 7% reported cutting back on their diabetes medications at least once per month. Moreover, 28% reported forgoing food or other essentials to pay medication costs, 14% increased their credit card debt, and 10% borrowed money from family or friends to pay for their prescriptions. Medication cost problems were especially common among respondents who were younger, had higher monthly out-of-pocket costs, and had no prescription drug coverage. In general, few respondents, including those reporting medication cost problems, reported that their health care providers had given them information or other assistance to address medication cost pressures.

CONCLUSIONS

Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence. Clinicians should actively identify patients with diabetes who are facing medication cost pressures and assist them by modifying their medication regimens, helping them understand the importance of each prescribed medication, providing information on sources of low-cost drugs, and linking patients with coverage programs.

Cost of pharmacological care of the elderly: implications for healthcare resources

Expenditures on prescribed medicines are significantly higher among those aged 65 years and over than among younger people. As populations in developed countries age so the cost of pharmacological care associated with the older population can be expected to increase. While pharmacological care represents only one component of healthcare, its costs are increasing rapidly because of advances in technology and increasing use. However, such costs should be considered within a context of decreasing disability in the elderly population, improving economic conditions among seniors and the relationship of these costs with those in other aspects of healthcare. Where medications have been demonstrated to be cost-effective, attempts to curtail expenditure growth may prove a false economy resulting in significantly higher growth elsewhere such as in the hospital and long-term care sectors. Policy responses to this issue should encompass the inclusion of elderly patients in clinical trials, the use of evidence-based principles of practice and strategies to ensure that this population obtain maximum benefit from medication through education and counselling.

Exploring the demand for a voluntary Medicare prescription drug benefit

The purposes of this study were (1) to assess the utility of the economic theory of demand for insurance for modeling voluntary Medicare drug benefit enrollment decisions and (2) to explore the degree of adverse selection and crowd-out that might occur under a voluntary enrollment Medicare prescription benefit. Data were collected using a cross-sectional, mail survey of 2,100 community-dwelling adults aged 65 and older in Wisconsin. Respondents were asked to evaluate their likelihood of enrollment in any of 4 hypothetical drug benefit plans under the assumption that they could enroll in one of the hypothetical plans or maintain their current coverage. Data analyses included bivariate comparisons across enrollment likelihood categories and logit analysis of enrollment likelihood as a function of respondent characteristics. 1041 usable survey forms were returned for an adjusted response rate of 51.5%. Older adults with 4 or more chronic conditions were most likely to report that they were "very likely" to enroll in one of the hypothetical drug plans, as were those with the highest out-of-pocket drug spending in the previous 30 days. Respondents with no or self-purchased drug benefits were more likely than those with employer-based plans to express a higher likelihood of enrollment in one of the hypothetical plans. Adverse selection may be problematic for a voluntary enrollment Medicare drug benefit. Given that high out-of-pocket drug spending (secondary to drug coverage source) was a consistent predictor of enrollment likelihood, demand-side factors affecting the crowding out of employer-based drug coverage sources by a voluntary enrollment drug benefit appear minimal. However, the availability of a Medicare prescription benefit may still lead to crowd-out through employer incentives.

Income-related differences in the use of evidence-based therapies in older persons with diabetes mellitus in for-profit managed care

OBJECTIVES

To determine whether income influences evidence-based medication use by older persons with diabetes mellitus in managed care who have the same prescription drug benefit.

DESIGN

Observational cohort design with telephone interviews and clinical examinations.

SETTING

Managed care provider groups that contract with one large network-model health plan in Los Angeles County.

PARTICIPANTS

A random sample of community-dwelling Medicare beneficiaries with diabetes mellitus aged 65 and older covered by the same pharmacy benefit.

MEASUREMENTS

Patients reported their sociodemographic and clinical characteristics. Annual household income (> or =$20,000 or <$20,000) was the primary predictor. The outcome variable was use of evidence-based therapies determined by a review of all current medications brought to the clinical examination. The medications studied included use of any cholesterol-lowering medications, use of 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors (statins) for cholesterol lowering, aspirin for primary and secondary prevention of cardiovascular disease, and angiotensin-converting enzyme (ACE) inhibitors in those with diabetic nephropathy. The influence of income on evidence-based medication use was adjusted for other patient characteristics.

RESULTS

The cohort consisted of 301 persons with diabetes mellitus, of whom 53% had annual household income under $20,000. In unadjusted analyses, there were lower rates of use of all evidence-based therapies and lower rates of statin use for persons with annual income under $20,000 than for higher-income persons. In multivariate models, statin use was observed in 57% of higher-income versus 30% of lower-income respondents with a history of hyperlipidemia (P =.01) and 66% of higher-income versus 29% of lower-income respondents with a history of myocardial infarction (P =.03). There were no differences by income in the rates of aspirin or ACE inhibitor use.

CONCLUSION

Among these Medicare managed care beneficiaries with diabetes mellitus, all of whom had the same pharmacy benefit, there were low rates of use of evidence-based therapies overall and substantially lower use of statins by poorer persons.

National trends in use of medications in office-based practice, 1985-1999

Increases in physician office visits involving the use or prescribing of a drug were observed between 1985 and 1999 using data from the National Ambulatory Medical Care Survey. The prescription rate increased from 109 to 146 prescriptions per 100 visits. Growth in drug mention rates for specific therapeutic classes varied by patients' age. The rate of multiple prescriptions per visit rose 39 percent. Similar-size increases were observed after differences in patients' age, number of comorbidities, source of payment, and physician specialty were controlled for.