Topical corticosteroid prescribing patterns following changes in drug benefit status

Impact of Drug Plan Management Policies in Canada: A Systematic Review

Background/objective:

In Canada, pharmaceutical expenditures require an increasing proportion of total health care dollars. Drug plan managers use various policies to manage medication use and control costs, but these policies can have unintended consequences. The objective of this systematic review is to evaluate the impact of drug policies on economic, clinical and humanistic (quality of life or satisfaction) outcomes.

Methods:

Articles in which the primary objective was to evaluate the impact of a drug policy tool or technique in Canada and that measured one or more economic, clinical or humanistic outcomes were considered for inclusion. Studies were excluded if they were based in institutions or not published in peer-reviewed journals. The search process included searching 9 electronic databases, searching the reference lists of identified articles and working papers and contacting drug policy researchers. Studies were assessed for quality and suitability for meta-analysis. We performed a qualitative synthesis of the study design, study sample and outcomes.

Results:

Thirty-five articles satisfied the inclusion criteria. Most ( n= 25, 71%) determined that drug policies reduced the costs, utilization or both of the studied drug therapy. Only 13 studies (37%) measured the impact of the drug policy on the cost or utilization of medical care, and the impact of the policy was favourable in only 4 of these cases. Six studies (17%) evaluated the impact of the policy on clinical outcomes; none reported a favourable impact. No studies evaluated the impact of the drug policy on humanistic outcomes.

Discussion:

Although the drug policies in most of the studies included in this systematic review did achieve the desired goal of reducing drug costs, utilization or both, the impact on other outcomes was seldom examined. In the 6 studies in which clinical outcomes were included in the evaluation framework, the impact was inconclusive. Humanistic outcomes have been completely excluded from evaluations to date.

Prescription drug cost sharing: associations with medication and medical utilization and spending and health

CONTEXT

Prescription drugs are instrumental to managing and preventing chronic disease. Recent changes in US prescription drug cost sharing could affect access to them.

OBJECTIVE

To synthesize published evidence on the associations among cost-sharing features of prescription drug benefits and use of prescription drugs, use of nonpharmaceutical services, and health outcomes.

DATA SOURCES

We searched PubMed for studies published in English between 1985 and 2006.

STUDY SELECTION AND DATA EXTRACTION

Among 923 articles found in the search, we identified 132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance (n = 65), pharmacy benefit caps or monthly prescription limits (n = 11), formulary restrictions (n = 41), and reference pricing (n = 16), and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.

RESULTS

Increased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.

CONCLUSIONS

Pharmacy benefit design represents an important public health tool for improving patient treatment and adherence. While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.