Cost-sharing policies can be made more tolerable by fully covering ≥1 drug in each therapeutically equivalent group and/or by allowing patients to pay deductibles gradually so that they receive some coverage at all times.
The results of the present analysis suggest that the IBD policy, a plan that broadly applied income-based deductibles and coinsurance payments to most drugs for most families, likely increased the risk for adverse health outcomes among older users of inhaled medi- cations compared with full coverage. Increases in emergency CAE admissions and physician visits were observed to be greater under IBD policy coverage than the fixed copay policy coverage. This inference is strengthened by the observation of an apparent direct link between discontinuation of inhaler use and emergency hospital admissions, which increased under IBD coverage. However, we were unable to determine whether there were carryover effects from the fixed copay policy into the IBD period.
To patients using inhaled corticosteroids in BC, the 25% coinsurance rate under the IBD policy cost roughly as much as a $25 copayment because the average cost of an inhaled corticosteroid prescription in 2003 was $110 (ie, a $27.50 coinsurance payment). A 25% coinsurance payment would have typically been <$25 for the less expensive β2-agonist and anticholinergic classes, suggesting that the overall increase in emergency CAE admissions that occurred during IBD policy coverage may have been influenced by the deductible component of the policy, which left patients without any public coverage until they passed the deductible.
The findings from this study are compatible with those from prior analyses that found that users of long-term inhaled corticosteroids were 21% more likely to discontinue inhaled corticosteroid use during IBD policy coverage and that patients newly diagnosed with asthma or COPD were 24% less likely to start using inhaled corticosteroids during the first year of the IBD policy period compared with full coverage.17
The results from the current analysis suggest a direct link between increased discontinuation of inhaler medication use under the IBD policy and an increased risk for CAE emergency admissions adjusted for any such association at baseline. Our strict definition of stopping
inhaler use (within 60 days to lapse after the end of medication use without receiving a refill) may have led to misclassification of some stoppers as nonstoppers, possibly resulting in a conservative estimation.
The increased risk for CAE emergency hospitalization observed during IBD policy coverage might be cause for concern because hospitalization is a compelling marker for clinically relevant deterioration in health status, and it exposes patients to greater risk for other adverse outcomes, such as infections. Alternatively, increased hospitalizations could have occurred in some patients in the absence of clinically significant deteriorations in health status. For example, it is possible that, after losing the psychological comfort of their inhalers, some patients with COPD contacted their physicians, who might have chosen to be cautious by sending such patients to the hospital. If true, that scenario would beg the question of what responsibility a drug plan has to meet a patient’s expectations of drug therapy beyond the therapeutic evidence for its use. Randomized controlled trial methodology—the “gold standard” for evaluating drug effects—purposely tests for therapeutic benefits beyond placebo effects, and drugs found to be no more effective than placebo are not covered. Should a parallel be drawn to policy interventions in which policy effects produced by placebo effects are also discounted?
The change in diagnostic coding in hospital records from ICD-9-CM to ICD-10 in April 2001 might have been an alternative explanation for the observed increase in emergency hospitalizations, as the coding change could have caused patients to be classified differently. Fortunately, the diagnostic coding change occurred early in the baseline period, and as a safeguard we combined COPD, asthma, and emphysema into a single disease grouping (CAE) to reduce the likelihood of bias resulting from misclassification. The present cohort design with concurrent controls would have inherently adjusted for a secular change in COPD classification with respect to time.
The clinical importance of increased physician visits is unclear. The modest increase in physician visits might have been the consequence of physicians’ seeing patients more frequently as policy-induced changes were made to their drug regimens31
or patients’ requesting less expensive drug therapies, receiving closer monitoring because of medication changes, receiving assistance coping with more frequent or severe symptoms, or obtaining free drug samples. A previous study of reference pricing in BC concluded that policy-mandated medication switching was associated with an increase in physician visits of 11% (95% CI, 7%–15%).5
BC residents did not have to pay for medically necessary visits to a physician. However, starting in January 2002, the Ministry of Health ceased to pay for chiropractic, massage therapy, naturopathy, physical therapy, and nonsurgical podiatry services in most patients. To ensure that these changes did not affect our analysis, we excluded visits for those services from both the pre- and postpolicy data. Some patients might have had private insurance coverage for prescription drugs and/or supplemental medical services, such as podiatry and optometry. We did not have access to private insurance data. Private insurance might have introduced bias if the controls had different insurance coverage than the policy intervention groups. The primary analysis used an identically defined historical control group, which would have been expected to have avoided such bias. Any bias from private insurance data in these analyses, if it existed, was expected to have been toward the null because these patients would have had more coverage than we observed.
This study found that a combined deductible and coinsurance drug plan was associated with increased adverse health outcomes among these older users of inhaled medications. Increased discontinuation of use of inhaler medications was the apparent causal intermediary to increased emergency CAE hospitalizations. From a health plan’s perspective, a coinsurance policy would be preferable to a copayment policy because patient cost-sharing amounts automatically increase as prices increase. From a patient’s perspective, however, coinsurance payments become less affordable as prices increase, and a deductible that exposes patients to a period of no drug coverage may be particularly risky. Two modifications that could reasonably be expected to make these types of polices better tolerated would be to fully cover ≥1 drug in each essential therapeutic class, similar to reference drug programs,5
and/or allowing enrollees to pay their deductibles in installments so that they receive some coverage at all times during the year. BC has already implemented the latter option. Covering one essential drug in each class is also likely to reduce morbidity and insurance plan costs.32