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1.  The impact of increasing patient prescription drug cost sharing on therapeutic classes of drugs received and on the health status of elderly HMO members. 
Health Services Research  1997;32(1):103-122.
OBJECTIVE: To assess the impact of increased prescription drug copayments on the therapeutic classes of drugs received and health status of the elderly. HYPOTHESES TESTED: Increased prescription drug copayments will reduce the relative exposure to, annual days use of, and prescription drug costs for drugs used in self-limiting conditions, but will not affect drugs used in progressive chronic conditions and will not reduce health status. STUDY DESIGN: Each year over a three-year period, one or the other of two well-insured Medicare risk groups in an HMO setting had their copayments per dispensing increased. Sample sizes ranged from 6,704 to 7,962. DATA SOURCES/DATA COLLECTION: Automated administrative data systems of the HMO were used to determine HMO eligibility, prescription drug utilization, and health status. ANALYSIS DESIGN: Analysis of variance or covariance was employed to measure change in dependent variables. FINDINGS: Relative exposure, annual days of use, and prescription drug costs for drugs used in self-limiting conditions and in progressive chronic conditions were not affected in a consistent manner across years by increases in prescription drug copayment. Health status may have been adversely affected. Larger increases in copayments appeared to generate more changes. CONCLUSIONS: Small changes in copayments did not appear to substantially affect outcomes. Large changes in copayments need further examination.
PMCID: PMC1070172  PMID: 9108807
2.  How Effective Are Copayments in Reducing Expenditures for Low-Income Adult Medicaid Beneficiaries? Experience from the Oregon Health Plan 
Health Services Research  2008;43(2):515-530.
To determine the impact of introducing copayments on medical care use and expenditures for low-income, adult Medicaid beneficiaries.
Data Sources/Study Setting
The Oregon Health Plan (OHP) implemented copayments and other benefit changes for some adult beneficiaries in February 2003.
Study Design
Copayment effects were measured as the “difference-in-difference” in average monthly service use and expenditures among cohorts of OHP Standard (intervention) and Plus (comparison) beneficiaries.
Data Collection/Extraction Methods
There were 10,176 OHP Standard and 10,319 Plus propensity score-matched subjects enrolled during November 2001–October 2002 and May 2003–April 2004 that were selected and assigned to 59 primary care-based service areas with aggregate outcomes calculated in six month intervals yielding 472 observations.
Total expenditures per person remained unchanged (+2.2 percent, p = .47) despite reductions in use (−2.7 percent, p<.001). Use and expenditures per person decreased for pharmacy (−2.2 percent, p<.001; −10.5 percent, p<.001) but increased for inpatient (+27.3 percent, p<.001; +20.1 percent, p = .03) and hospital outpatient services (+13.5 percent, p<.001; +19.7 percent, p<.001). Ambulatory professional (−7.7 percent, p<.001) and emergency department (−7.9 percent, p = .03) use decreased, yet expenditures remained unchanged (−1.5 percent, p = .75; −2.0 percent, p = .68, respectively) as expenditures per service user rose (+6.6 percent, p = .13; +7.9 percent, p = .03, respectively).
In the Oregon Medicaid program applying copayments shifted treatment patterns but did not provide expected savings. Policy makers should use caution in applying copayments to low-income Medicaid beneficiaries.
PMCID: PMC2442363  PMID: 18248405
Medicaid; cost-sharing; medical expenditures
3.  Impact of Multitiered Copayments on the Use and Cost of Prescription Drugs among Medicare Beneficiaries 
Health Services Research  2008;43(2):478-495.
To assess the impact of multitiered copayments on the cost and use of prescription drugs among Medicare beneficiaries.
Data Sources
Marketscan 2002 Medicare Supplemental and Coordination of Benefits database and Plan Benefit Design database.
Study Design
The study uses cross-sectional variation in copayment structures among firms with a self-insured retiree health plan to measure the impact of number of copayment tiers on total and enrollee drug payments, number of prescriptions filled, and generic substitution. The study also assesses the effect of enrollee cost sharing on the cost and use of prescription medications for the long-term treatment of chronic conditions.
Data Collection Methods
We linked plan enrollment and benefit data with medical and drug claims for 352,760 Medicare beneficiaries with employer-sponsored retiree drug coverage.
Primary Findings
Medicare beneficiaries in three-tiered plans had 14.3 percent lower total drug expenditures, 14.6 percent fewer prescriptions filled, and 57.6 percent higher out-of-pocket costs than individuals in lower tiered plans. They also had fewer brand name and generic prescriptions filled, and a higher percentage of generics. The estimated price elasticity of demand for prescription drug expenditures was −0.23. Finally, for maintenance medications used for the long-term treatment of chronic conditions, members in three-tiered plans had 11.5 percent fewer prescriptions filled.
Higher tiered drug plans reduce overall expenditures and the number of prescriptions purchased by Medicare beneficiaries. Beneficiaries are less responsive to cost sharing incentives when using drugs to treat chronic conditions.
PMCID: PMC2442369  PMID: 18370964
Prescription drugs; cost sharing; Medicare
4.  Medicaid Expansion Initiative in Massachusetts: Enrollment Among Substance-Abusing Homeless Adults 
American journal of public health  2013;103(11):2007-2013.
We assessed whether homeless adults entering substance abuse treatment in Massachusetts were less likely than others to enroll in Medicaid after implementation of the MassHealth Medicaid expansion program in 1997.
We used interrupted time-series analysis in data on substance abuse treatment admissions from the Treatment Episode Data Set (1992–2009) to evaluate Medicaid coverage rates in Massachusetts and to identify whether trends differed between homeless and housed participants. We also compared Massachusetts data with data from 17 other states and the District of Columbia combined.
The percentage of both homeless and housed people entering treatment with Medicaid increased approximately 21% after expansion (P = .01), with an average increase of 5.4% per year over 12 years (P = .01). The increase in coverage was specific to Massachusetts, providing evidence that the MassHealth policy was the cause of this increase.
Findings provide evidence in favor of state participation in the Medicaid expansion in January 2014 under the Affordable Care Act and suggest that hard-to-reach vulnerable groups such as substance-abusing homeless adults are as likely as other population groups to benefit from this policy.
PMCID: PMC3828691  PMID: 24028262
5.  Effect of Copayments on Use of Outpatient Mental Health Services Among Elderly Managed Care Enrollees 
Medical care  2011;49(3):281-286.
Recent parity legislation will require many insurers and the federal Medicare program to reduce mental health copayments, so that they are equivalent to copayments for other covered services. The effect of changes in mental health cost sharing has not been well studied, particularly among elderly populations.
To examine the consequences of increasing and decreasing copayments on the use of outpatient mental health services among the elderly.
Research Design
Difference-in-differences (DID) design comparing the use of outpatient mental health care in Medicare plans that changed mental health copayments compared with concurrent trends in matched control plans with unchanged copayments.
Study Population
A total of 1,147,916 enrollees aged 65 years and older in 14 Medicare plans that increased copayments by ≥25%, 3 plans that decreased copayments by ≥25%, and 17 matched control plans with unchanged copayments.
In 14 plans that increased mental health copayments from a mean of $14.43 to $21.07, the proportion of enrollees who used mental health services remained at 2.2% in the year before and year after the increase (adjusted DID, 0.1 percentage points; 95% confidence interval, 0.0–0.1). Among 3 plans that decreased copayments from a mean of $25.00 to $8.33, utilization rates were 1.2% before and after the decrease (adjusted DID, 0.1 percentage points; 95% confidence interval, −0.2 to 0.3). Stratified analyses by age, gender, race, and presence of a disability yielded similar results.
Few older adults in managed care plans used outpatient mental health services. Among this population, increasing or decreasing mental health copayments had negligible effects on the likelihood of using outpatient mental health care.
PMCID: PMC3970196  PMID: 21301371
Cost sharing; mental health services/utilization; health insurance benefits; Medicare; managed care
6.  Effects of Prescription Coinsurance and Income-Based Deductibles on Net Health Plan Spending for Older Users of Inhaled Medications 
Medical care  2009;47(5):508-516.
Health plans that increase prescription cost-sharing for their patients may increase overall plan costs. We analyzed the impact on health plan spending of a switch in public drug insurance from full coverage to a prescription copayment (copay), and then to income-based deductibles plus coinsurance (IBD).
We studied British Columbia residents 65 years of age or older who were dispensed inhaled steroids, β2 agonists or anticholinergics on or after January 1996. Multivariable linear regression was used to estimate health plan costs for the population using inhalers by the Ministry of Health (MOH) during the copay and IBD policies. We estimated costs for excess physician visits and emergency hospitalizations based on data from a previously published cohort study and cost data from the MOH. We estimated the net change in MOH spending as the sum of changes in spending for inhalers, physician visits, hospitalizations, and policy administration costs.
Net health plan spending increased by C$1.98 million per year during the copay policy [95% confidence interval (CI): 0.10–4.34], and C$5.76 million per year during the first 10 months of the IBD policy (95% CI: 1.75–10.58). Out-of-pocket spending by older patients increased 30% during the copay policy (95% CI: 24–36) and 59% during the IBD policy (95% CI: 56–63).
British Columbia’s experience indicates that cost containment focused on cost-shifting to patients may increase net expenditures for the treatment of some diseases. Health plans should consult experts to anticipate the potential cross-program impacts of policy changes.
PMCID: PMC2905667  PMID: 19365295
pharmacoeconomics; inhaled medications; asthma; COPD; health care utilization; drug benefit plans; health services research
7.  Impact of 3-Tier Formularies on Drug Treatment of Attention-Deficit/Hyperactivity Disorder in Children 
Archives of general psychiatry  2005;62(4):435-441.
Expenditures for medications used to treat attention-deficit/hyperactivity disorder (ADHD) in children have increased rapidly. Many employers and health plans have adopted 3-tier formularies in an attempt to control costs for these and other drugs.
To assess the effect of copayment increases associated with 3-tier formulary adoption on use and spending patterns for ADHD medications for children.
Design and Setting
Observational study using quasi-experimental design to compare effects on ADHD medication use and spending for children enrolled as dependents in an employer-sponsored plan that made major changes to its pharmacy benefit design and a comparison group of children covered by the same insurer. The plan simultaneously moved from a 1-tier (same copayment required for all drugs) to a 3-tier formulary and implemented an across-the-board copayment increase. The plan later moved 3 drugs from tier 3 to tier 2.
An intervention group of 20326 and a comparison group of 15776 children aged 18 years and younger.
Main Outcome Measures
Monthly probability of using an ADHD medication; plan, enrollee, and total ADHD medication spending; and medication continuation.
A 3-tier formulary implementation resulted in a 17% decrease in the monthly probability of using medication (P<.001), a 20% decrease in expected total medication expenditures, and a substantial shifting of costs from the plan to families (P<.001). Intervention group children using medications in the pre-period were more likely to change to a medication in a different tier after 3-tier adoption, relative to the comparison group (P = .08). The subsequent tier changes resulted in increased plan spending (P<.001) and decreased patient spending (P = .003) for users but no differences in continuation.
The copayment increases associated with 3-tier formulary implementation by 1 employer resulted in lower total ADHD medication spending, sizeable increases in out-of-pocket expenditures for families of children with ADHD, and a significant decrease in the probability of using these medications.
PMCID: PMC1403292  PMID: 15809411
8.  The Effect of Copayments for Prescriptions on Adherence to Prescription Medicines in Publicly Insured Populations; A Systematic Review and Meta-Analysis 
PLoS ONE  2013;8(5):e64914.
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.
To quantify the risk of non-adherence to prescribed medicines in publicly insured populations exposed to copayments.
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.
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.
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.
PMCID: PMC3665806  PMID: 23724105
9.  Emergency Hospital Admissions After Income-Based Deductibles and Prescription Copayments in Older Users of Inhaled Medications 
Clinical therapeutics  2008;30(Spec No):1038-1050.
Rapid growth in prescription drug costs has compelled insurers to require increased patient cost-sharing.
The aim of this study was to compare the effects of 2 recent cost-sharing policies on emergency hospitalizations due to chronic obstructive pulmonary disease, asthma, or emphysema (CAE), and on physician visits.
We analyzed data from a large-scale natural experiment in British Columbia (BC), Canada. The cost-sharing policies were a fixed copayment policy (fixed copay policy) and an income-based deductible (IBD) policy with 25% coinsurance (IBD policy). Prescription, physician billing, and hospitalization records were obtained from the BC Ministry of Health. From the total population of BC residents ≥65 years of age, we extracted data from all patients dispensed an inhaled corticosteroid, β2-agonist, or anticholinergic from June 30, 1997, to April 30, 2004. Poisson regression was used to evaluate the impact of the policies in a cohort of patients receiving long-term inhaler treatment. An identically defined historical control group unaffected by the policy changes was used for comparison.
The study population included 37,320 users of long-term inhaled medications from the BC population of 576,000 persons ≥65 years of age. During the IBD period but not the fixed copay period, emergency hospitalizations for CAE increased 41% (95% CI for adjusted rate ratio [RR], 1.24–1.60) in patients ≥65 years of age. There was also a significant increase in physician visits of 3% (95% CI for adjusted RR, 1.01–1.05). No significant increases were observed during the fixed copay period. In a secondary analysis using a concurrent control group, we estimated a smaller but significant increase in emergency CAE hospitalizations of 29% (95% CI for adjusted RR, 1.09–1.52). This analysis also showed increases in physician visits (fixed copay period RR, 1.03 [95% CI for adjusted RR, 1.01–1.05]; IBD period RR, 1.07 [95% CI for adjusted RR, 1.05–1.08]).
The results suggest that the IBD policy was likely associated with an increased risk for emergency hospitalization and physician visits in these users of inhaled medications who were aged ≥65 years.
PMCID: PMC2905670  PMID: 18640478
inhaled medications; asthma; COPD; health care utilization; health outcomes; drug benefit plans; health services research; pharmacoeconomics
10.  Demand for Weight Loss Counseling After Copayment Elimination 
Overweight and obesity are public health issues in the United States, and veterans have a higher rate of overweight and obesity than the general population. Our objective was to examine whether copayment elimination increased use of a weight loss clinic by veterans.
We examined clinic use by 44,411 new patients seen in a Veterans Affairs (VA) MOVE! weight management clinic before the copayment elimination and clinic use by 64,398 new patients seen in the year after copayment elimination. We examined clinic use via mixed-effects models for patients who were already exempt from copayment and patients who were newly exempt from copayment. We used 2 outcomes before and after copayment elimination: 1) the ratio of number of clinic visits by new users with the mean number of MOVE! clinic visits by all users, and 2) the number of clinic visits by each new user in the 6 months after their first visit. All models were adjusted for patient and clinic factors.
Among newly exempt patients, the clinic-standardized rate of new use increased by 2.2% after the copayment was eliminated but increased 12% among already exempt veterans. This finding was confirmed in adjusted analyses. Analysis of number of clinic visits adjusted for patient and clinic factors also found that exempt and nonexempt veterans had similar numbers of repeat clinic visits.
We saw an unexpected larger increase in demand among veterans who receive all VA care for free. These results suggest that VA should not assume that copayment reductions for selective preventive services will motivate patient change and achieve intended system-level outcomes.
PMCID: PMC3617989  PMID: 23557640
11.  Impact of a Prescription Copayment Increase on Lipid Lowering Medication Adherence in Veterans 
Circulation  2009;119(3):390-397.
In February 2002, the VA increased copayments from $2 to $7 per 30-day drug supply of each medication for many veterans. We examined the impact of the copayment increase on lipid lowering medication adherence.
Methods and Results
Quasi-experimental study using electronic records of 5,604 veterans receiving care at the Philadelphia VA Medical Center from November, 1999 to April, 2004. The “All Copayment” group included veterans subject to copayments for all drugs with no annual cap. Veterans subject to copayments for drugs only if indicated for a non-service connected condition with an annual cap of $840 for out-of-pocket costs comprised the “Some Copayment” group. Veterans who remained copayment exempt formed a natural control group (“No copayment” group). Patients were identified as “adherent” if the proportion of days covered (PDC) with lipid-lowering medications was >= 80%. Patients were identified as having a “continuous gap” if they had at least one continuous episode with no lipid lowering medications for >= 90 days. A difference-indifference approach comparing changes in lipid lowering medication adherence during the 24 months pre- and post- copayment increase among veterans subject to the copayment change versus those who were not.
Adherence declined in all three groups after the copayment increase. However, the percent of patients who were adherent (PDC>=80%) declined significantly more in the all copayment (-19.2%) and some copayment (-19.3%) groups relative to the exempt group (-11.9%). The incidence of a continuous gap increased significantly at twice the rate in both copayment groups (+24.6% all copayment group and 24.1% some copayment group) than the exempt group (+11.7%). Compared to the exempt group, the odds of having a continuous gap in the post- relative to the pre-period were significantly higher in both the all copayment group (OR 3.04 95% CI 2.29-4.03) and the some copayment group (OR 1.85 95% CI 1.43-2.40). Similar results were seen in subgroups of high CHD risk patients, high medication users, and elderly veterans.
The copayment increase adversely impacted lipid lowering medication adherence among veterans including those at high CHD risk.
PMCID: PMC2753258  PMID: 19139387
12.  Association between Drug Insurance Cost Sharing Strategies and Outcomes in Patients with Chronic Diseases: A Systematic Review 
PLoS ONE  2014;9(3):e89168.
Prescription drugs are used in people with hypertension, diabetes, and cardiovascular disease to manage their illness. Patient cost sharing strategies such as copayments and deductibles are often employed to lower expenditures for prescription drug insurance plans, but the impact on health outcomes in these patients is unclear.
To determine the association between drug insurance and patient cost sharing strategies on medication adherence, clinical and economic outcomes in those with chronic diseases (defined herein as diabetes, hypertension, hypercholesterolemia, coronary artery disease, and cerebrovascular disease).
Studies were included if they examined various cost sharing strategies including copayments, coinsurance, fixed copayments, deductibles and maximum out-of-pocket expenditures. Value-based insurance design and reference based pricing studies were excluded. Two reviewers independently identified original intervention studies (randomized controlled trials, interrupted time series, and controlled before-after designs). MEDLINE, EMBASE, Cochrane Library, CINAHL, and relevant reference lists were searched until March 2013. Two reviewers independently assessed studies for inclusion, quality, and extracted data. Eleven studies, assessing the impact of seven policy changes, were included: 2 separate reports of one randomized controlled trial, 4 interrupted time series, and 5 controlled before-after studies.
Outcomes included medication adherence, clinical events (myocardial infarction, stroke, death), quality of life, healthcare utilization, or cost. The heterogeneity among the studies precluded meta-analysis. Few studies reported the impact of cost sharing strategies on mortality, clinical and economic outcomes. The association between patient copayments and medication adherence varied across studies, ranging from no difference to significantly lower adherence, depending on the amount of the copayment.
Lowering cost sharing in patients with chronic diseases may improve adherence, but the impact on clinical and economic outcomes is uncertain.
PMCID: PMC3965394  PMID: 24667163
13.  Impact of reference-based pricing for angiotensin-converting enzyme inhibitors on drug utilization 
Increasing copayments for higher-priced prescription medications has been suggested as a means to help finance drug coverage for elderly patients, but evaluations of the impact of such policies are rare. The objective of this study was to analyze the effect of reference-based pricing of angiotensin- converting enzyme (ACE) inhibitors on drug utilization, cost savings and potential substitution with other medication classes.
We analyzed 36 months of claims data from British Columbia for 2 years before and 1 year after implementation of reference-based pricing (in January 1997). The 119 074 patients were community-living Pharmacare beneficiaries 65 years of age or older who used ACE inhibitors during the study period. The main outcomes were changes over time in use of ACE inhibitors, use of antihypertensive drugs and expenditures for antihypertensive drugs, as well as predictors of medication switching related to reference-based pricing.
We observed a sharp decline (29%) in the use of higher-priced cost-shared ACE inhibitors immediately after implementation of the policy (p < 0.001). After a transition period, the post-implementation utilization rate for all ACE inhibitors was 11% lower than projected from pre-implementation data. However, overall utilization of antihypertensives was unchanged (p = 0.40). The policy saved $6.7 million in pharmaceutical expenditures during its first 12 months. Patients with heart failure or diabetes mellitus who were taking a cost-shared ACE inhibitor were more likely to remain on the same medication after implementation of reference-based pricing (OR 1.12 [95% confidence interval, CI, 1.06–1.19] and 1.28 [95% CI 1.20–1.36] respectively). Patients with low-income status were more likely than those with high-income status to stop all antihypertensive therapy (OR 1.65 [95% CI 1.43–1.89]), which reflects a general trend toward discontinuation of therapy among these patients even before implementation of reference-based pricing.
Reference-based pricing in British Columbia achieved a sustained reduction in drug expenditures, and no changes in overall use of antihypertensive therapy were observed. Further research is needed on the overall health and economic effects of such policies.
PMCID: PMC99452  PMID: 11944760
14.  Effect of Switching to a High-Deductible Health Plan on Use of Chronic Medications 
Health Services Research  2011;46(5):1382-1401.
To examine whether high-deductible health plans (HDHPs) that exempt prescription drugs from full cost sharing preserve medication use for major chronic illness, compared with traditional HMOs with similar drug cost sharing.
Data Sources/Study Setting
We examined 2001–2008 pharmacy claims data of 3,348 continuously enrolled adults in a Massachusetts health plan for 9 months before and 24 months after an employer-mandated switch from a traditional HMO plan to a HDHP, compared with 20,534 contemporaneous matched HMO members. Both study groups faced similar three-tiered drug copayments. We calculated daily medication availability for all prescription drugs and four chronic medication classes: hypoglycemics, lipid-lowering agents, antihypertensives, and chronic obstructive pulmonary disease (COPD)/asthma controllers.
Study Design
Interrupted time-series with comparison group study design examining monthly level and trend changes in prescription drug utilization.
Principal Findings
The HDHP and control groups had comparable changes in the level and trend of all drugs after the index date; we detected similar patterns in the use of lipid-lowering agents, antihypertensives, and COPD/asthma controllers. Some evidence suggested a small relative decline in hypoglycemic use among diabetic patients in HDHPs.
Switching to an HDHP that included modest drug copayments did not change medication availability or reduce use of essential medications for three common chronic illnesses.
PMCID: PMC3207183  PMID: 21413983
High-deductible health plans; pharmaceutical use; chronic disease; differential cost-sharing
15.  The impact of generic-only drug benefits on patients' use of inhaled corticosteroids in a Medicare population with asthma 
Patients face increasing insurance restrictions on prescription drugs, including generic-only coverage. There are no generic inhaled corticosteroids (ICS), which are a mainstay of asthma therapy, and patients pay the full price for these drugs under generic-only policies. We examined changes in ICS use following the introduction of generic-only coverage in a Medicare Advantage population from 2003–2004.
Subjects were age 65+, with asthma, prior ICS use, and no chronic obstructive pulmonary disorder (n = 1,802). In 2004, 74.0% switched from having a $30 brand-copayment plan to a generic-only coverage plan (restricted coverage); 26% had $15–25 brand copayments in 2003–2004 (unrestricted coverage). Using linear difference-in-difference models, we examined annual changes in ICS use (measured by days-of-supply dispensed). There was a lower-cost ICS available within the study setting and we also examined changes in drug choice (higher- vs. lower-cost ICS). In multivariable models we adjusted for socio-demographic, clinical, and asthma characteristics.
In 2003 subjects had an average of 188 days of ICS supply. Restricted compared with unrestricted coverage was associated with reductions in ICS use from 2003–2004 (-15.5 days-of-supply, 95% confidence interval (CI): -25.0 to -6.0). Among patients using higher-cost ICS drugs in 2003 (n = 662), more restricted versus unrestricted coverage subjects switched to the lower-cost ICS in 2004 (39.8% vs. 10.3%). Restricted coverage was not associated with decreased ICS use (2003–2004) among patients who switched to the lower-cost ICS (18.7 days-of-supply, CI: -27.5 to 65.0), but was among patients who did not switch (-38.6 days-of-supply, CI: -57.0 to -20.3). In addition, restricted coverage was associated with decreases in ICS use among patients with both higher- and lower-risk asthma (-15.0 days-of-supply, CI: -41.4 to 11.44; and -15.6 days-of-supply, CI: -25.8 to -5.3, respectively).
In this elderly population, patients reduced their already low ICS use in response to losing drug coverage. Switching to the lower-cost ICS mitigated reductions in use among patients who previously used higher-cost drugs. Additional work is needed to assess barriers to switching ICS drugs and the clinical effects of these drug use changes.
PMCID: PMC2488344  PMID: 18638405
16.  Effect of Prescription Copayments on Adherence and Treatment Failure with Oral Antidiabetic Medications 
Pharmacy and Therapeutics  2008;33(9):532-553.
Previous studies have shown that an increase in cost sharing by patients for medications results in reduced medication use. The purpose of our study was to determine whether the amount of members’ copayments predicted oral antidiabetic treatment failure in a managed care population and to analyze the relationship between copayments, adherence to therapy, and hemoglobin A1c levels in patients with type-2 diabetes.
Health plan members 18 years of age or older with type-2 diabetes and who were newly initiated on an oral antidiabetic drug (OAD) between January 1, 2002, and January 31, 2006, were identified from a managed care population in the U.S. Members were required to have continuous eligibility for six or more months before and 12 months after the index prescription and were placed into four treatment groups. These patients were followed for one year. The time during which they took the index OAD was measured until treatment failure (discontinuation of therapy or a switch of the index OAD) or censoring of patient data. The medication possession ratio (MPR), which was used to calculate adherence, was defined as the number of days that a patient had a supply of the index OAD during the year after the index fill, divided by 365 days. Copays were identified for every prescription, and the amount for each 30 days of treatment was calculated. We used multivariate analyses to assess the impact of copays on treatment failure, adjusting for differences in member characteristics.
Adherence was poor, with an overall mean MPR of 0.57, decreasing from 0.58 for the group with a copay of less than $10 to 0.52 for patients with a copay of $20 or more. Initial treatment failed for 13,091 patients (70%), with approximately 60% of all members discontinuing treatment. This discontinuation rate ranged from 55% in the lowest copayment group (below $10) to 67% in those with a copay of $30 or more. For every $10 increase in copay, OAD treatment was 26% more likely to fail (95% confidence interval, 22.3–29.8%; P < 0.0001).
Higher copays for health plan members were a significant predictor of treatment failure. With the increased trend toward more cost sharing by members of health plans, ongoing evaluation will be necessary to determine the impact on treatment persistence in patients with chronic conditions.
PMCID: PMC2730132  PMID: 19750032
17.  Effect of an Expenditure Cap on Low-Income Seniors' Drug Use and Spending in a State Pharmacy Assistance Program 
Health Services Research  2009;44(3):1010-1028.
To estimate the impact of a soft cap (a ceiling on utilization beyond which insured enrollees pay a higher copayment) on low-income elders' use of prescription drugs.
Data Sources and Setting
Claims and enrollment files for the first year (June 2002 through May 2003) of the Illinois SeniorCare program, a state pharmacy assistance program, and Medicare claims and enrollment files, 2001 through 2003. SeniorCare enrolled non-Medicaid-eligible elders with income less than 200 percent of Federal Poverty Level. Minimal copays increased by 20 percent of prescription cost when enrollee expenditures reached $1,750.
Research Design
Models were estimated for three dependent variables: enrollees' average monthly utilization (number of prescriptions), spending, and the proportion of drugs that were generic rather than brand. Observations included all program enrollees who exceeded the cap and covered two periods, before and after the cap was exceeded.
Principle Findings
On average, enrollees exceeding the cap reduced the number of drugs they purchased by 14 percent, monthly expenditures decreased by 19 percent, and the proportion generic increased by 4 percent, all significant at p<.01. Impacts were greater for enrollees with greater initial spending, for enrollees without one of five chronic illness diagnoses in the previous calendar year, and for enrollees with lower income.
Near-poor elders enrolled in plans with caps or coverage gaps, including Part D plans, may face sharp declines in utilization when they exceed these thresholds.
PMCID: PMC2699919  PMID: 19291168
Prescription drugs; copayments; elasticity of demand; low-income elderly
18.  Utilization of the medical librarian in a state Medicaid program to provide information services geared to health policy and health disparities 
Objective: The role of two solo medical librarians in supporting Medicaid programs by functioning as information specialists at regional and state levels is examined.
Setting: A solo librarian for the Massachusetts Medicaid (MassHealth) program and a solo librarian for the New England States Consortium Systems Organization (NESCSO) functioned as information specialists in context to support Medicaid policy development and clinical, administrative, and program staff for state Medicaid programs.
Brief Description: The librarian for MassHealth initially focused on acquiring library materials and providing research support on culturally competent health care and outreach, as part of the United States Department of Health and Human Services Culturally and Linguistically Appropriate Services in Health Care Standards. The NESCSO librarian focused on state Medicaid system issues surrounding the implementation of the Health Insurance Portability and Accountability Act. The research focus expanded for both the librarians, shaping their roles to more directly support clinical and administrative policy development. Of note, the availability and dissemination of information to policy leaders facilitated efforts to reduce health disparities. In Massachusetts, this led to a state legislative special commission to eliminate health disparities, which released a report in November 2005. On a regional level, the NESCSO librarian provided opportunities for states in New England to share ideas and Medicaid program information. The Centers for Medicaid and Medicare are working with NESCSO to explore the potential for using the NESCSO model for collaboration for other regions of the United States.
Results/Outcomes: With the increased attention on evidence-based health care and reduction of health disparities, medical librarians are called on to support a variety of health care information needs. Nationally, state Medicaid programs are being called on to provide coverage and make complex medical decisions regarding the delivery of benefits. Increasing numbers of beneficiaries and shrinking Medicaid budgets demand effective and proactive decision making to provide quality care and to accomplish the missions of state Medicaid programs. In this environment, the opportunities for information professionals to provide value and knowledge management are increasing.
PMCID: PMC1435841  PMID: 16636710
19.  Income-, education- and gender-related inequalities in out-of-pocket health-care payments for 65+ patients - a systematic review 
In all OECD countries, there is a trend to increasing patients' copayments in order to balance rising overall health-care costs. This systematic review focuses on inequalities concerning the amount of out-of-pocket payments (OOPP) associated with income, education or gender in the Elderly aged 65+.
Based on an online search (PubMed), 29 studies providing information on OOPP of 65+ beneficiaries in relation to income, education and gender were reviewed.
Low-income individuals pay the highest OOPP in relation to their earnings. Prescription drugs account for the biggest share. A lower educational level is associated with higher OOPP for prescription drugs and a higher probability of insufficient insurance protection. Generally, women face higher OOPP due to their lower income and lower labour participation rate, as well as less employer-sponsored health-care.
While most studies found educational and gender inequalities to be associated with income, there might also be effects induced solely by education; for example, an unhealthy lifestyle leading to higher payments for lower-educated people, or exclusively gender-induced effects, like sex-specific illnesses. Based on the considered studies, an explanation for inequalities in OOPP by these factors remains ambiguous.
PMCID: PMC2925341  PMID: 20701794
Archives of internal medicine  2009;169(8):10.1001/archinternmed.2009.62.
Increased cost-sharing reduces utilization of prescription drugs, but there is little evidence about the exact mechanisms by which this reduction occurs or the factors associated with price-sensitivity.
We conducted a retrospective cohort study of 272,474 elderly individuals with employer-provided drug coverage from 1997 to 2002 from 59 different health plans. We assessed the relationship between prescription drug cost-sharing and the time until the initiation of drug therapy after a new diagnosis of hypertension, hypercholesterolemia, or diabetes.
For all study conditions, higher copayments were associated with delayed initiation of therapy. In survival models, doubling copayments resulted in large reductions in the predicted proportion of patients initiating pharmacotherapy at one and five years after diagnosis (55.0 vs 40.1% at 1 year and 81.7% vs 66.3% at 5 years, p<0.000 for hypertension; 40.2% vs 31.1% at 1 year and 64.3% vs 53.8% at 5 years, p<0.002 for hypercholesterolemia; 45.8% vs 40.0% at 1 year and 69.3% vs 62.9% at 5 years, p<0.041 for diabetes). However, patients’ rate of initiation and sensitivity to copayments strongly depended upon their prior experience with prescription drugs. Those with a history of prior drug use initiated earlier and were less price-sensitive. These results were robust to a wide range of sensitivity analyses.
High cost-sharing delays the initiation of drug therapy for patients newly diagnosed with chronic disease. This effect is greater among patients who lack experience with prescription drugs. Policy makers and physicians should consider the effects of benefits design on patient behavior in order to encourage the adoption of necessary care.
PMCID: PMC3875311  PMID: 19398684
21.  Increasing Time Costs and Copayments for Prescription Drugs: An Analysis of Policy Changes in a Complex Environment 
Health services research  2011;46(3):900-919.
To estimate the effect of two separate policy changes in the North Carolina Medicaid program; the first reduced prescription lengths from 100 to 34 days' supply and the second increased copayments for brand name medications.
Data Sources/Study Setting
Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000 – December 31, 2002.
Study Design
We used a pre-post controlled partial difference-in-difference-in-differences (DDD) design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures.
Data Collection/Extraction Methods
Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant or deceased in the quarter were excluded.
Principal Findings
Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy but the copayment policy resulted in a net increase in Medicaid expenditures.
Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees.
PMCID: PMC3087836  PMID: 21306363
Medicaid; prescription drugs; chronic medications; days' supply
22.  Increasing Time Costs and Copayments for Prescription Drugs: An Analysis of Policy Changes in a Complex Environment 
Health Services Research  2011;46(3):900-919.
To estimate the effect of two separate policy changes in the North Carolina Medicaid program: (1) reduced prescription lengths from 100 to 34 days' supply, and (2) increased copayments for brand name medications.
Data Sources/Study Setting
Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000–December 31, 2002.
Study Design
We used a pre–post controlled partial difference-in-difference-in-differences design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures.
Data Collection/Extraction Methods
Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant, or deceased in the quarter were excluded.
Principal Findings
Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy, but the copayment policy resulted in a net increase in Medicaid expenditures.
Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees.
PMCID: PMC3087836  PMID: 21306363
Medicaid; prescription drugs; chronic medications; days' supply
23.  Income-based drug benefit policy: impact on receipt of inhaled corticosteroid prescriptions by Manitoba children with asthma 
Drug benefit policies are an important determinant of a population's use of prescription drugs. This study was undertaken to determine whether a change in a provincial drug benefit policy, from a fixed deductible and copayment system to an income-based deductible system, resulted in changes in receipt of prescriptions for inhaled corticosteroids by Manitoba children with asthma.
Using Manitoba's health care administrative databases, we identified a population-based cohort of 10 703 school-aged children who met our case definition for asthma treatment before and after the province's drug benefit policy was changed in April 1996. The effects of the program change on the probability of receiving a prescription for an inhaled corticosteroid and on the mean number of inhaled corticosteroid doses dispensed were compared between a group of children insured under other drug programs (the comparison group) and 2 groups of children insured under the deductible program: those living in low-income neighbourhoods and those living in higher-income neighbourhoods. All analyses were adjusted for a measure of asthma severity.
For higher-income children with severe asthma who were covered by the deductible program, the probability of receiving an inhaled corticosteroid prescription and the mean annual number of inhaled corticosteroid doses declined after the change to the drug policy. A trend toward a decrease in receipt of prescriptions was also observed for low-income children, but receipt of prescriptions was unaltered in the comparison group. Before the policy change, among children with severe asthma, the mean annual number of inhaled corticosteroid doses was lowest for low-income children, and this pattern persisted after the change. Among children with mild to moderate asthma, those covered by the deductible program (both low income and higher income) were less likely to receive prescriptions for inhaled corticosteroids than those in the comparison group, and this difference was statistically significant for the higher-income children.
The change to an income-based drug benefit policy was associated with a decrease in the use of inhaled corticosteroids by higher-income children with severe asthma and did not improve use of these drugs by low- income children.
PMCID: PMC81497  PMID: 11599328
24.  Male-female differences in mental health visits under cost-sharing. 
Health Services Research  1986;21(2 Pt 2):341-350.
This article, which was prepared as part of a larger study of the impact of the copayment requirement on United Mine Workers of America (UMWA) beneficiaries carried out at the National Center for Health Services Research (NCHSR), compares male to female changes in ambulatory care visits for mental disorders and discusses the implications of these changes for the use of other services and for the quality of care. Figures were derived from aggregate claims data provided by the UMWA for the time periods immediately preceding the introduction of copayment (full coverage for all health care) and the first year following the introduction of copayment. Our findings suggest that, at least as far as visits for mental disorders are concerned, copayment may reduce necessary visits. The men in our population, who sought care for mental disorders more sparingly than women and for more severe complaints, were most affected by copayment.
PMCID: PMC1068955  PMID: 3721876
25.  Effects of Increased Patient Cost Sharing on Socioeconomic Disparities in Health Care 
Journal of General Internal Medicine  2008;23(8):1131-1136.
Increasing patient cost sharing is a commonly employed mechanism to contain health care expenditures.
To explore whether the impact of increases in prescription drug copayments differs between high- and low-income areas.
Using a database of 6 million enrollees with employer-sponsored health insurance, econometric models were used to examine the relationship between changes in drug copayments and adherence with medications for the treatment of diabetes mellitus (DM) and congestive heart failure (CHF).
Individuals 18 years of age and older meeting prespecified diagnostic criteria for DM or CHF were included.
Median household income in the patient’s ZIP code of residence from the 2000 Census was used as the measure of income. Adherence was measured by medication possession ratio: the proportion of days on which a patient had a medication available.
Patients in low-income areas were more sensitive to copayment changes than patients in high- or middle-income areas. The relationship between income and price sensitivity was particularly strong for CHF patients. Above the lowest income category, price responsiveness to copayment rates was not consistently related to income.
The relationship between medication adherence and income may account for a portion of the observed disparities in health across socioeconomic groups. Rising copayments may worsen disparities and adversely affect health, particularly among patients living in low-income areas.
PMCID: PMC2517964  PMID: 18443882
health care costs; socioeconomic factors; vulnerable populations; health insurance; pharmaceutical care

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