Is 50 cent the price of the optimal copayment? - a qualitative study of patient opinions and attitudes in response to a 50 cent charge on prescription drugs in a publicly funded health system in Ireland

A systematic review of strategies used for controlling consumer moral hazard in health systems

Background

Consumer moral hazard refers to an increase in demand for health services or a decrease in preventive care due to insurance coverage. This phenomenon as one of the most evident forms of moral hazard must be reduced and prevented because of its important role in increasing health costs. This study aimed to determine and analyze the strategies used to control consumer moral hazards in health systems.

Methods

In this systematic review. Web of Sciences, PubMed, Scopus, Embase, ProQuest, Iranian databases(Magiran and SID), and Google Scholar engine were searched using search terms related to moral hazard and healthcare utilization without time limitation. Eligible English and Persian studies on consumer moral hazard in health were included, and papers outside the health and in other languages were excluded. Thematic content analysis was used for data analysis.

Results

Content analysis of 68 studies included in the study was presented in the form of two group, six themes, and 11 categories. Two group included “changing behavior at the time of receiving health services” and “changing behavior before needing health services.” The first group included four themes: demand-side cost sharing, health savings accounts, drug price regulation, and rationing of health services. The second approach consisted of two themes Development of incentive insurance programs and community empowerment.

Conclusion

Strategies to control consumer moral hazards focus on changing consumer consumptive and health-related behaviors, which are designed according to the structure of health and financing systems. Since “changing consumptive behavior” strategies are the most commonly used strategies; therefore, it is necessary to strengthen strategies to control health-related behaviors and develop new strategies in future studies. In addition, in the application of existing strategies, the adaptation to the structure of the health and financing system, and the pattern of consumption of health services in society should be considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-08613-y.

Study on microbial community of "green-covering" Tuqu and the effect of fortified autochthonous Monascus purpureus on the flavor components of light-aroma-type Baijiu

"Green-covering" Tuqu (TQ), as one of Xiaoqu, is a special fermentative starter (also known as Jiuqu in Chinese) that originated in southern China and is characterized by a layer of green mold covering (Aspergillus clavatus) the surface and (sometimes) with a red heart. It plays a vital role in producing light-aroma-type Baijiu (LATB). However, to date, the microbiota that causes red heart of TQ remain largely unexplored, and it is still unclear how these microbiota influence on the quality of LATB. In this study, two types of TQ, one with a red heart (RH) and another with a non-red heart (NRH), were investigated by high throughput sequencing (HTS) and directional screening of culture-dependent methods. The obtained results revealed the differences in the microbial communities of different TQ and led to the isolation of two species of Monascus. Interestingly, the results of high performance liquid chromatography (HPLC) detection showed that citrinin was not detected, indicating that Monascus isolated from TQ was no safety risk, and the contents of gamma-aminobutyric acid in the fermented grains of RH were higher than that of NRH during the fermentation. Selecting the superior autochthonous Monascus (M1) isolated from the TQ to reinoculate into the TQ-making process, established a stable method for producing the experimental "red heart" Tuqu (ERH), which confirmed that the cause of "red heart" was the growth of Monascus strains. After the lab-scale production test, ERH increased ethyl ester production and reduced higher alcohols production. In addition, Monascus had an inhibitory effect on the growth of Saccharomyces and Aspergillus. This study provides the safe, health-beneficial, and superior fermentation strains and strategies for improving the quality of TQ and LATB.

Effects of Monascus on Proteolysis, Lipolysis, and Volatile Compounds of Camembert-Type Cheese during Ripening

In order to improve the flavor and taste of Camembert cheese, the use of Monascus as an adjunct starter for the production of Camembert-type cheese was studied to investigate its effect on the proteolysis, lipolysis, and volatile compounds during ripening for 40 days. The Camembert cheese without Monascus was used as a control. The results showed that proteolytic and lipolytic activities increased to a certain extent. The addition of Monascus promoted primary and secondary proteolysis, due to the release of some proteases by Monascus. Aspartic, Threonine, Glutamic, Glycine, Methione, Isoleucine, Phenyalanine, and Lysine contents in experimental group (R) cheese were significantly higher than those in control group (W) cheeses. In addition, the free amino acid and fatty acid contents were also affected. The identification of flavor components using gas-mass spectrometry (GC-MS) showed that 2-undecone, 2-tridecanone, phenylethyl alcohol, butanediol (responsible for the production of flowery and honey-like aroma), ethyl hexanoate, ethyl octanoate, and ethyl citrate (fruit-like aroma) were significantly higher (p < 0.05) in the experimental cheeses than in the control. The contents of 2-nonanone, 2-octanone and 2-decanone (showing milky flavor), and 1-octene-3 alcohol with typical mushroom-like flavor were lower than the control.

Lack of the Histone Methyltransferase Gene Ash2 Results in the Loss of Citrinin Production in Monascus purpureus

ABSTRACT

Absent, small, or homeotic discs 2 (Ash2), a histone H3K4 methyltransferase complex, has been implicated in the control of hyphal development and secondary metabolism in many kinds of filamentous fungi. We constructed an Ash2 deletion mutant (ΔAsh2) by using an Agrobacterium-mediated gene knockout method to investigate the function of the Ash2 gene in the mold Monascus purpureus. Lack of the Ash2 gene resulted in the formation of a lower colony phenotype with fluffy aerial hyphae that autolyzed as the colony grew on potato dextrose agar at 30°C. The production of pigments and the number of conidia were significantly lower in the ΔAsh2 than in the wild type. Citrinin production by the ΔAsh2 was not detected during 15 days of fermentation. Relative expression levels of secondary metabolite regulatory genes PigR and CTNR, secondary metabolite synthesizing genes PKSPT and CTN, key genes of mitogen-activated protein kinase pathway Spk1 and its downstream gene mam2, the conidium development control gene BrlA, and global regulatory genes LaeA and VeA were detected by the quantitative real-time PCR. These results indicate that the Ash2 gene is involved in conidial germination, pigment production, and citrinin production and plays a key role in development and secondary metabolism in M. purpureus.

HIGHLIGHTS

The impact of prescription drug co-payments for publicly insured families

Co-payments for prescription drugs are a common feature of many healthcare systems, although often with exemptions for vulnerable population groups. International evidence demonstrates that cost-sharing for medicines may delay necessary care, increase use of other forms of healthcare and result in poorer health outcomes. Existing studies concentrate on adults and older people, particularly in the US, with relatively less attention afforded to paediatric and European populations. In Ireland, prescription drug co-payments were introduced for the first time for medical cardholders (i.e. those with public health insurance) in October 2010, initially at a cost of €0.50 per item, rising to €1.50 in January 2013, and further increasing to €2.50 in December 2013. Using data from the Growing Up in Ireland longitudinal study of children, and a difference-in-difference research design, we estimate the impact of the introduction (and increase) of these co-payments on health, healthcare utilisation and household financial wellbeing. The introduction of modest co-payments on prescription items was not estimated to impinge on the health of children and parents from low-income families. For the younger Infant Cohort, difference-in-difference estimates indicated that the introduction (and increase) in co-payments was associated with a decrease in GP visits and hospital nights, and a decrease in the proportion of households reporting 'difficulties with making ends meet'. In contrast, for the older cohort of children (the Child Cohort), co-payments were associated with an increase in GP visiting, and an increase in household deprivation. While the parallel trends assumption for difference-in-difference analysis appeared to be satisfied, further investigation revealed that there were other time-varying observable factors (such as exposure to the economic recession over the period) that affected the treatment and control groups, as well as the two cohorts of children differentially, that may partly explain these divergent results. For example, while the analysis suggests that the introduction of the €0.50 co-payment in 2010 was associated with an increase in the probability of treated families in the Child Cohort being deprived by 9.4 percentage points, the proportion of treated families experiencing unemployment and reductions in household income also increased significantly around the time of the co-payment introduction. This highlights the difficulty in identifying the effect of the co-payment policy in an environment in which assignment to the treatment (i.e. medical cardholder status) was not randomly assigned.

Out of pocket or out of control: A qualitative analysis of healthcare professional stakeholder involvement in pharmaceutical policy change in Ireland

BACKGROUND

Mandatory co-payments attached to prescription medicines on the Irish public health insurance [General Medical Services (GMS)] scheme have undergone multiple iterations since their introduction in October 2010. To date, whilst patients' opinions on said co-payments have been evaluated, the perspectives of community pharmacists and general practitioners (GPs) have not.

OBJECTIVE

To explore the involvement and perceptions of community pharmacists and GPs on this pharmaceutical policy change.

METHODS

A qualitative study using purposive sampling alongside snowballing recruitment was used. Nineteen interviews were conducted in a Southern region of Ireland. Data were analysed using the Framework Approach.

RESULTS

Three major themes emerged: 1) the withered tax-collecting pharmacist; 2) concerns and prescribing patterns of physicians; and 3) the co-payment system - impact and sustainability. Both community pharmacists and GPs accepted the theoretical concept of a co-payment on the GMS scheme as it prevents moral hazard. However, there were multiple references to the burden that the current method of co-payment collection places on community pharmacists in terms of direct financial loss and reductions in workplace productivity. GPs independently suggested that a co-payment system may inhibit moral hazard by GMS patients in the utilisation of GP services. It was unclear to participants what evidence is guiding the GMS co-payment fee changes.

CONCLUSION

Interviewees accepted the rationale for the co-payment system, but reform is warranted.

Patients' attitudes toward copayments as a steering tool-results from a qualitative study in Norway and Germany

BACKGROUND

Copayments are implemented in many health care systems. The effect of copayments differs between countries. Up to now, patients' attitudes regarding copayments are mainly unknown.

OBJECTIVES

Thus, the goal of our analysis was to explore adult patients' attitudes in Germany and Norway towards copayments as a steering tool.

METHODS

We conducted a qualitative comparative study. Episodic interviews were conducted with 40 patients in Germany and Norway. The interviews were analysed by thematic coding in the framework of grounded theory. All text segments related to copayments were analysed in depth for emerging topics and types.

RESULTS

We found three dimensions of patients' attitudes towards copayments: the perceived steering effect, the comprehensibility, and the assessment of copayments. The perceived steering effect consists of three types: having been influenced by copayments, not having experienced any influence and the experience of other persons to be influenced. The category comprehensibility describes that not all patients understand rules and regulations of copayments and its caps. The assessment of copayments consists of nine subcategories, three of which are rather negative and six of which are rather positive. In all three dimensions the patterns between the German and Norwegian sub-samples differ considerably.

CONCLUSIONS

The results of our study point at the importance of communicating clear rules for copayments which are easily comprehensible.

Patient acceptability and experiences of therapeutic switching of proton pump inhibitors within the National Preferred Drugs initiative in Ireland

INTRODUCTION

A 'Preferred Drugs' initiative was introduced into Ireland in 2013. This identified a single recommended drug to be prescribed to patients requiring treatment from a particular class of drugs.

AIMS

This study investigates how patients on established proton pump inhibitor (PPI) therapy experienced the therapeutic switching of their medication to the 'preferred drug', and the extent to which they regarded it as an acceptable practice.

METHODS

The experiences of 61 patients on established proton pump inhibitor (PPI) therapy were sought before and after their drug was switched to the 'preferred drug'.

RESULTS

Eighty per cent of patients were happy to switch medications. When asked for their opinions on medications in general, 71% felt doctors should prescribe the least expensive medication, 84% agreed that all licensed medications were safe while 67% felt their GP changing medication for cost reasons was safe. After 8 weeks, 20% of patients had switched back to their old PPI. When asked how they felt about their medication change, 74% felt happy or pleased.

CONCLUSIONS

The majority of patients in our study were satisfied to have their medication switched. However, prescribers should be mindful that 1 in 5 patients encountered problems as a result of the switching process.

The implications of regional and national demographic projections for future GMS costs in Ireland through to 2026

BACKGROUND

As the health services in Ireland have become more resource-constrained, pressure has increased to reduce public spending on community drug schemes such as General Medical Services (GMS) drug prescribing and to understand current and future trends in prescribing. The GMS scheme covers approximately 37% of the Irish population in 2011 and entitles them, inter alia, to free prescription drugs and appliances. This paper projects the effects of future changes in population, coverage, claims rates and average claims cost on GMS costs in Ireland.

METHODS

Data on GMS coverage, claims rates and average cost per claim are drawn from the Primary Care Reimbursement Service (PCRS) and combined with Central Statistics Office (CSO) (Regional and National Population Projections through to 2026). A Monte Carlo Model is used to simulate the effects of demographic change (by region, age, gender, coverage, claims rates and average claims cost) will have on GMS prescribing costs in 2016, 2021 and 2026 under different scenarios.

RESULTS

The Population of Ireland is projected to grow by 32% between 2007 and 2026 and by 96% for the over 70s. The Eastern region is estimated to grow by 3% over the lifetime of the projections at the expense of most other regions. The Monte Carlo simulations project that females will be a bigger driver of GMS costs than males. Midlands region will be the most expensive of the eight old health board regions. Those aged 70 and over and children under 11 will be significant drivers of GMS costs with the impending demographic changes. Overall GMS medicines costs are projected to rise to €1.9bn by 2026.

CONCLUSIONS

Ireland's population will experience rapid growth over the next decade. Population growth coupled with an aging population will result in an increase in coverage rates, thus the projected increase in overall prescribing costs. Our projections and simulations map the likely evolution of GMS cost, given existing policies and demographic trends. These costs can be contained by government policy initiatives.