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.
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.
Medicaid; cost-sharing; medical expenditures
To assess the impact of multitiered copayments on the cost and use of prescription drugs among Medicare beneficiaries.
Marketscan 2002 Medicare Supplemental and Coordination of Benefits database and Plan Benefit Design database.
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.
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.
Prescription drugs; cost sharing; Medicare
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.
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.
pharmacoeconomics; inhaled medications; asthma; COPD; health care utilization; drug benefit plans; health services research
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.
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.
inhaled medications; asthma; COPD; health care utilization; health outcomes; drug benefit plans; health services research; pharmacoeconomics
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.
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.
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.
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.
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.
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.
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.
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.
Prescription drugs; copayments; elasticity of demand; low-income elderly
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.
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.
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.
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.
Medicaid; prescription drugs; chronic medications; days' supply
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.
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.
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.
health care costs; socioeconomic factors; vulnerable populations; health insurance; pharmaceutical care
Introduced to sensitize people to the cost of prescription drugs, copayments may be archaic in the era of biologic therapies. The risk is great that high copayments for specialty drugs effectively become a denial of possibly life-saving care.
As more biologics aimed at larger patient populations come to market, the effectiveness and appropriateness of copayments comes into question. This classic cost-sharing tool – developed for an earlier era’s less expensive products – may not work in the biotech era.
Patient copayments for all medical services have increased dramatically. There are few data available regarding how copayments have changed for services commonly considered to be quality indicators.
Describe the relative change in copayments for services used as quality indicators and interventions subject to programs to control utilization.
A large claims database was used to assess copayment changes from 2001 to 2006 for selected drug and non-drug services in patient cohorts with specific chronic diseases.
Approximately 5 million commercially-insured individuals enrolled in a variety of fee-for-service and capitated health plans.
Copayment trends were calculated as the change in the average amount paid per unit service from 2001 to 2006.
Out-of-pocket payments for services targeted by quality improvement initiatives increased substantially [>50%] and in a similar magnitude to interventions subject to programs to control their use. For prescription drugs, the trend was driven more by copayment increases for branded medications [$10 per prescription] than for generic drugs [$2 per prescription]. Copayments for non-drug preventive services rose modestly.
Benefit designers should consider reversing the trend of copayment increases for services considered to be indicators of high quality care.
copayments; costs; payments
Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to $10–$25 copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003.
PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models.
Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates.
Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.
OBJECTIVE: To examine the cost-effectiveness of community-based mental health care. DATA SOURCES/STUDY SETTING: Administrative data from Medicaid and the Massachusetts Department of Mental Health; primary data from 144 psychiatrically disabled adult Medicaid beneficiaries who lived in Boston, central Massachusetts, and western Massachusetts. STUDY DESIGN: A cross-sectional observational study compared the costs and outcomes of treatment in three different types of public mental health service systems. DATA COLLECTION/EXTRACTION METHODS: Beneficiaries, randomly sampled from outpatient mental health programs, were interviewed about their mental health status. All their acute treatment and long-term continuing care for the preceding year were abstracted from Medicaid and Department of Mental Health files. Costs were extracted from Medicaid paid claims and from Department of Mental Health contracts and other financial documents. PRINCIPAL FINDINGS: Clients in the region allocating a greater proportion of its Department of Mental Health budget to community support services used far fewer hospital days, resulting in lower per person treatment expenditures. Outcomes, however, were not significantly different from outcomes of clients in the other regions. For all regions, substance abuse comorbidity increased hospitalization and total treatment costs. An individual-level cost-effectiveness analysis identified western Massachusetts (community-based care) as significantly more cost effective than the other two regions. CONCLUSIONS: Systems with stronger community-based orientation are more cost effective.
After a change in Quebec's policy on drug coverage in August 1996, elderly patients' copayments for prescription drugs increased. We assessed the impact of this drug policy reform on prescribing patterns for essential cardiac medications, utilization of medical care and related health outcomes after acute myocardial infarction.
Patients at least 65 years of age who experienced acute myocardial infarction between 1994 and 1998 were identified through the Quebec discharge summary database. Drug claims databases were analyzed to determine rates of prescription of essential cardiac medications for cohorts of patients admitted before and after the policy reform. The impact on readmissions for cardiac-related complications, outpatient visits to physicians and emergency departments, and mortality rate was also assessed.
The proportion of patients who received prescriptions for β-blockers, angiotensin-converting enzyme inhibitors and lipid-lowering drugs increased over time and, more specifically, did not appear to decline with the change in the drug policy. In addition, the policy reform did not appear to affect persistence of drug therapy (the proportion of time for which patients were covered by prescriptions over the year after discharge). There was no within-class shift from more to less expensive drugs. Use of cardiac procedures increased over time, but this increase was unrelated to the date of the policy reform. Finally, rates of readmission for complications, visits to individual physicians and to emergency departments, and mortality rate were unchanged. The findings did not vary with sex or socioeconomic status.
Prescriptions for essential cardiac medications and care related to acute myocardial infarction in elderly patients did not change with increases in out-of-pocket copayment, regardless of sex or socioeconomic status.
To evaluate the effects of patient copayment and coinsurance policies on adherence to therapy with β-adrenergic blocking agents (β-blockers) and on the rate of initiation of β-blocker therapy after acute myocardial infarction (MI) in a population-based natural experiment.
Three sequential cohorts included British Columbia residents age 66 years and older who initiated β-blocker therapy during time intervals with full drug coverage (2001), a $10 or $25 copayment (2002), and 25% coinsurance (2003–2004). We used linked data on all prescription drug dispensings, physician services, and hospitalizations. Follow-up of each cohort was 9 months after the policy changes.
We measured the proportion of subjects in each cohort who were adherent to β-blocker therapy over time, with adherence defined as having ≥80% of days covered. We also measured the proportion of patients initiating β-blocker therapy after acute MI. Policy effects were evaluated using multivariable regression.
Adherence to β-blocker therapy was marginally reduced as a consequence of the copayment policy (−1.3 percentage points, 95% confidence interval [CI] = −2.5, −0.04) or the coinsurance policy (−0.8 percentage points, 95% CI = −2.0, 0.3). The proportion of patients initiating β-blockers after hospitalization for acute MI remained steady at about 61% during the study period, similar to that observed in a control population of elderly Pennsylvania residents with full drug coverage.
Fixed patient copayment and coinsurance policies had little negative effect on adherence to relatively inexpensive β-blocker therapy, or initiation of β-blockers after acute MI.
Despite the increasing enrollment of adult disabled beneficiaries into Medicaid managed care organizations (MCOs) there is little evidence of its (hoped for) effectiveness at reducing Medicaid expenditures.
To evaluate the impact of Medicaid MCOs on health care expenditures for adults with disabilities.
I employ a repeated observations design comparing individual monthly Medicaid expenditures across beneficiaries who reside in counties with mandatory, voluntary, and no MCOs. County-level Medicaid MCO program status for adults with disabilities was merged with the Medical Expenditure Panel Survey and the Area Resource File for 1996–2004. Two-part regression models are used to estimate the probability and level of Medicaid expenditure.
Working age Medicaid beneficiaries who receive Supplement Security Income for disability comprise the sample of 1,613 individuals.
Outcome measures include total and service-specific Medicaid expenditures.
On average, total monthly Medicaid expenditures per beneficiary do not differ between FFS and MCO counties although some service-specific spending differs. Relative to FFS counties, average monthly Medicaid spending per beneficiary is higher for prescription medications in voluntary ($24) and mandatory ($25) MCO counties. Average Medicaid monthly spending for other medical care and dental care is $4 – $11 higher per beneficiary in MCO relative to FFS counties.
Medicaid MCO programs as implemented are not associated with lower Medicaid spending; thus, state Medicaid programs should consider additional policy tools to contain health care expenditures in this population.
The study used a convenience sample of patients undergoing surveillance following curative treatment for localized cancer who completed a paper survey to estimate the maximum copayment patients are willing to pay for better treatment outcomes. Results suggest that patients may be less willing to pay high copayments for treatments with modest benefit. In addition, sociodemographic factors such as education and employment status were associated with willingness to pay.
Cost sharing, intended to control the “overuse” of health care resources, may also reduce use of necessary services. The influence of cost on the treatment choices of patients with life-threatening illness, such as cancer, is unknown.
A convenience sample of patients undergoing surveillance following curative treatment for localized cancer completed a paper survey that included three scenarios to elicit the maximum copayment they would be willing to pay for better treatment outcomes. Scenario A described a treatment for a curable cancer in terms of recurrence risk. Scenarios B and C described treatments for noncurable cancer in terms of the 2-year survival probability and median life expectancy.
The sample (n = 60) was 78% female, 83% aged <65 years, and 58% college graduates. Thirteen percent reported making financial sacrifices to pay for treatment. Patients were willing to pay higher copayments for more effective treatments (p < .05 for all three scenarios). In scenario B, patients who were employed demonstrated a greater willingness to pay (WTP) (odds ratio [OR], 12.6; 95% confidence interval [CI], 2.0–80.4), when controlling for efficacy. In scenario C, college graduates showed greater WTP (OR, 5.0; 95% CI, 1.2–20.9) and patients who reported previous financial sacrifices showed lower WTP (OR, 0.2; 95% CI, 0.04–0.6).
This pilot study suggests that patients may be less willing to pay high copayments for treatments with modest benefit. Even among this relatively young, affluent, and educated population, demographic variables were related to WTP. Larger studies in more diverse populations should be conducted to better understand how cost may influence treatment decisions and cancer treatment outcomes.