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

Interruptions in Insurance Coverage and Prescription Drug Utilization: Evidence from Kentucky

This study examined how interruptions in insurance coverage affect purchases of prescription drugs for young adults. It used data spanning 2014 to 2018 from Kentucky's prescription drug monitoring program, which tracked the universe of federally-regulated (Schedule II-V) prescription drugs dispensed in the state. The study employed a regression discontinuity design based on the age limit at 26 for dependent insurance coverage for children. At age 26, the probability of purchasing a prescription decreased by 5%, with all subcategories of prescriptions affected. The share of generic prescriptions increased for stimulants (the only category observed with substantial branded prescriptions). By age 27, prescription purchases returned to levels observed at 25, but the share purchased with public insurance and the generic share for stimulants remained higher. The findings suggest that interruptions in insurance coverage decrease prescription drug utilization by young adults and that public insurance programs such as Medicaid are important for resuming treatment.

The role of insurance policies in the drug pricing landscape

INTRODUCTION

This overview paper aims at summarizing and analyzing the available literature on healthcare system organization and pricing policies of 11 European countries, comparing them to the Bulgarian pharmaceutical system. The countries were selected based on the reference basket for the pricing of pharmaceuticals in Bulgaria - Belgium, Greece, Spain, Italy, Latvia, Lithuania, Romania, Slovakia, Slovenia, and France.

AREAS COVERED

In the first part, we explore the health system models in the above-mentioned countries. In the second part we explore the pricing and reimbursement policies, and in the third part we analyze healthcare and pharmaceutical economic indicators, as well as life expectancy. The major focus of the review is the outpatient care.

EXPERT OPINION

In this work, we attempted to outline differences and similarities between the countries of interest. Despite the differences in their healthcare system organization, health and pharmaceutical expenditures constantly increased during the observed 2 decades. This increase in expenditures, however, has not had a significant impact on life-expectancy. Minor increases were observed - from 2 to 4 years total. No country had an expectancy above 85 years of age. It might be said that other factors are influencing the life expectancy to a greater extent.

Monitoring progress towards universal health coverage in Europe: a descriptive analysis of financial protection in 40 countries

Background

Ensuring that access to health care is affordable for everyone-financial protection-is central to universal health coverage (UHC). Financial protection is commonly measured using indicators of financial barriers to access (unmet need for health care) and financial hardship caused by out-of-pocket payments for health care (impoverishing and catastrophic health spending). We aim to assess financial hardship and unmet need in Europe and identify the coverage policy choices that undermine financial protection.

Methods

We carry out a cross-sectional study of financial hardship in 40 countries in Europe in 2019 (the latest available year of data before COVID-19) using microdata from national household budget surveys. We define impoverishing health spending as out-of-pocket payments that push households below or further below a relative poverty line and catastrophic health spending as out-of-pocket payments that exceed 40% of a household's capacity to pay for health care. We link these results to survey data on unmet need for health care, dental care, and prescribed medicines and information on two aspects of coverage policy at country level: the main basis for entitlement to publicly financed health care and user charges for covered services.

Findings

Out-of-pocket payments for health care lead to financial hardship and unmet need in every country in the study, particularly for people with low incomes. Impoverishing health spending ranges from under 1% of households (in six countries) to 12%, with a median of 3%. Catastrophic health spending ranges from under 1% of households (in two countries) to 20%, with a median of 6%. Catastrophic health spending is consistently concentrated in the poorest fifth of the population and is largely driven by out-of-pocket payments for outpatient medicines, medical products, and dental care-all forms of treatment that should be an essential part of primary care. The median incidence of catastrophic health spending is three times lower in countries that cover over 99% of the population than in countries that cover less than 99%. In 16 out of the 17 countries that cover less than 99% of the population, the basis for entitlement is payment of contributions to a social health insurance (SHI) scheme. Countries that give greater protection from user charges to people with low incomes have lower levels of catastrophic health spending.

Interpretation

It is challenging to identify with certainty the coverage policy choices that undermine financial protection due to the complexity of the policies involved and the difficulty of disentangling the effects of different choices. The conclusions we draw are therefore tentative, though plausible. Countries are more likely to move towards UHC if they reduce out-of-pocket payments in a progressive way, decreasing them for people with low incomes first. Coverage policy choices that seem likely to achieve this include de-linking entitlement from payment of SHI contributions; expanding the coverage of outpatient medicines, medical products, and dental care; limiting user charges; and strengthening protection against user charges, particularly for people with low incomes.

Funding

The European Union (DG SANTE and DG NEAR) and the Government of the Autonomous Community of Catalonia, Spain.

Big Data-Enabled Analysis of Factors Affecting Medical Expenditure in the Cerebral Infarction of a Developing City in Western China

Purpose

Cerebral infarction (CI) has been one of the leading causes of death in China since 2017, and controlling the medical expenses of this disease is an urgent issue for the Chinese government. This study aims to explore the important factors that affect the hospitalization expenses of CI patients and to provide a scientific basis for establishing a reasonable reimbursement mechanism and hospitalization expense standard for CI patients.

Methods

Data from 109,314 inpatients from the Healthcare Security Administration of Chengdu in western China from January 2016 to December 2018 were utilized. Descriptive statistical analysis was used for variable characteristic analysis. The Mann-Whitney test and Kruskal-Wallis test were used for single-factor analysis, and multiple linear stepwise regression was used for single-factor analysis and multiple-factor analysis.

Results

This study found that the average direct economic burden of CI in Chengdu was approximately 10,569 Chinese yuan (CNY), about 1450 US dollars, the average length of stay (LOS) was 14.47 days, the indirect economic burden was approximately 2817 CNY, and the total economic burden was 13,386 CNY for a CI inpatient. Gender, insurance type, grade of medical institution, the level of payment type, age, LOS, and complications and comorbidities (CCs) are the most important factors affecting CI medical costs.

Conclusion

Citizens should improve their lifestyle habits to reduce disease risk to avoid the associated medical and economic burdens. Hospitals should improve their medical technology to decrease the LOS and reduce direct medical costs. The government should actively promote the hierarchical diagnosis and treatment policy to reduce the waste of medical resources caused by low-acuity patients going to high-level hospitals for treatment. The National Healthcare Security Administration should optimize the medical insurance payment method and establish a corresponding mechanism to reduce the occurrence of excessive medical treatments such as overuse.

The rising cost of rhinologic medications

BACKGROUND

The high prescription drug cost in the United States may negatively affect patient prognosis and treatment compliance.

OBJECTIVE

To fill the knowledge gap and inform clinicians regarding rhinology medications price changes by evaluating trends in price changes of highly used nasal sprays and allergy medications.

METHODS

The 2014-2020 Medicaid National Average Drug Acquisition Cost database was queried for drug pricing information for the following classes of medications: intranasal corticosteroids, oral antihistamines, antileukotrienes, intranasal antihistamines, and intranasal anticholinergics. Individual medications were identified by Food and Drug Administration-assigned National Drug Codes. Per unit, drug prices were analyzed for average annual prices, average annual percentage price changes, and inflation-adjusted annual and composite percentage price changes.

RESULTS

Beclometasone (Beconase AQ, 56.7%, QNASL, 77.5%), flunisolide (Nasalide, -14.6%), budesonide (Rhinocort Aqua, -1.2%), fluticasone (Flonase, -6.8%, Xhance, 11.7%), mometasone (Nasonex, 38.2%), ciclesonide (Omnaris, 73.8%), combination azelastine and fluticasone (Dymista, 27.3%), loratadine (Claritin, -20.5%), montelukast (Singulair, 14.5%), azelastine (Astepro, 21.9%), olopatadine (Patanase, 27.3%), and ipratropium bromide (Atrovent, 56.6%) had an overall change in inflation-adjusted per unit cost between 2014 and 2020 (% change). Of 14 drugs evaluated, 10 had an increase in inflation-adjusted prices, for an average increase of 42.06% ± 22.27%; 4 of 14 drugs had a decrease in inflation-adjusted prices, for an average decrease of 10.78% ± 7.36%.

CONCLUSION

The rising cost of highly used medications contributes to increased patient acquisition costs and may pose barriers of drug adherence to particularly vulnerable populations.

The Associations of Prescription Drug Insurance and Cost-Sharing With Drug Use, Health Services Use, and Health: A Systematic Review of Canadian Studies

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.