Economic Outcomes Following Combinatorial Pharmacogenomic Testing for Elderly Psychiatric Patients.

OBJECTIVE: We compared economic outcomes when elderly patients with neuropsychiatric disorders received psychotropic medications guided by a combinatorial pharmacogenomic (PGx) test. METHODS: This is a subanalysis of a 1-year prospective assessment of medication cost for patients with neuropsychiatric disorders receiving combinatorial PGx testing. Pharmacy claims were used to compare per member per year (PMPY) medication cost for patients ≥65 and <65 years old when medications were congruent or incongruent with the PGx test. Polypharmacy was also assessed. RESULTS: Congruent prescribing was associated with savings of US$3497 PMPY (P < .001) for patients ≥65 years and US$2467 PMPY (P < .001) for patients <65, compared to incongruent prescribing. Congruent prescribing in patients ≥65 treated by primary care providers was associated with US$4113 PMPY (P = .026) in savings, while congruent prescribing by psychiatrists was associated with US$120 PMPY (P = .719). Congruent prescribing was also associated with one fewer neuropsychiatric medication for patients ≥65 (P = .070). CONCLUSION: Congruence with PGx testing was associated with medication cost savings in elderly patients.

Real-World Direct Health Care Costs Associated with Psychotropic Polypharmacy Among Adults with Common Cancer Types in the United States.

BACKGROUND: Psychotropic polypharmacy is not uncommon among cancer patients and may contribute to the increased direct health care cost burden in this population. OBJECTIVE: To estimate average direct health care costs in the year following cancer diagnosis among cancer patients receiving psychotropic polypharmacy compared with those without psychotropic polypharmacy, using a multivariable analysis framework. METHODS: A retrospective cross-sectional study was conducted among patients aged 18 years and older diagnosed with the most commonly occurring cancers (breast, prostate, lung, and colorectal) in the United States during 2011-2012 using the deidentified Optum Clinformatics Data Mart commercial claims database. Psychotropic polypharmacy was defined as concurrent use of 2 or more psychotropic medications for at least 90 days. Direct health care costs in the year following cancer diagnosis were estimated as total medical payments made by the health plans and were derived from claims files. A generalized linear regression model with log-link function and gamma distribution was used to model average direct health care costs, controlling for baseline patient demographic and clinical covariates. RESULTS: Average annual direct health care costs for cancer patients with psychotropic polypharmacy ($53,497; SD $72,590) were higher than those without psychotropic polypharmacy ($38,255; SD $59,844), with an unadjusted average cost difference of $15,242 (P < 0.0001). In the adjusted regression model, the average difference in costs shrunk to $5,888 but remained notable. When examined by type of cancer, average direct health care costs for all cancer patients with psychotropic polypharmacy were significantly higher than those for patients without psychotropic polypharmacy, except for colorectal cancer patients. CONCLUSIONS: Overall health care costs were higher among cancer patients with psychotropic polypharmacy compared with those without psychotropic polypharmacy. Our findings support the need for future research to better understand the benefits and risks of psychotropic polypharmacy, given its potential to cause adverse health outcomes and avoidable health care utilization and costs for this vulnerable patient population. DISCLOSURES: This study was funded by the American Association of Colleges of Pharmacy (AACP) New Investigator Award mechanism, which was received by Vyas. Aroke was partially supported by the AACP grant for conducting data analysis of the study. Kogut is partially supported by Institutional Development Award Number U54GM115677 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health and the AACP. The authors report no conflicts of interest. An abstract of this study was presented as a poster at the American Association of Colleges of Pharmacy Annual Meeting on July 22, 2018, in Boston, MA.

High-Expenditure Pharmaceutical Use Among Children in Medicaid.

BACKGROUND AND OBJECTIVES: Medication use may be a target for quality improvement, cost containment, and research. We aimed to identify medication classes associated with the highest expenditures among pediatric Medicaid enrollees and to characterize the demographic, clinical, and health service use of children prescribed these medications. METHODS: Retrospective, cross-sectional study of 3 271 081 Medicaid-enrolled children. Outpatient medication spending among high-expenditure medication classes, defined as the 10 most expensive among 261 mutually exclusive medication classes, was determined by using transaction prices paid to pharmacies by Medicaid agencies and managed care plans among prescriptions filled and dispensed in 2013. RESULTS: Outpatient medications accounted for 16.6% of all Medicaid expenditures. The 10 most expensive medication classes accounted for 63.9% of all medication expenditures. Stimulants (amphetamine-type) accounted for both the highest proportion of expenditures (20.6%) and days of medication use (14.0%) among medication classes. Users of medications in the 10 highest-expenditure classes were more likely to have a chronic condition of any complexity (77.9% vs 41.6%), a mental health condition (35.7% vs 11.9%), or a complex chronic condition (9.8% vs 4.3%) than other Medicaid enrollees (all P < .001). The 4 medications with the highest spending were all psychotropic medications. Polypharmacy was common across all high-expenditure classes. CONCLUSIONS: Medicaid expenditure on pediatric medicines is concentrated among a relatively small number of medication classes most commonly used in children with chronic conditions. Interventions to improve medication safety and effectiveness and contain costs may benefit from better delineation of the appropriate prescription of these medications.

The cost-effectiveness of deep brain stimulation for patients with treatment-resistant obsessive-compulsive disorder.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a chronic neuropsychiatric disorder with a 2% to 3% lifetime prevalence; in addition, 10% of OCD patients are resistant to conventional therapy. Deep brain stimulation (DBS) has been an effective treatment for treatment resistant OCD patients (TROCD). We aimed to determine the cost-effectiveness of DBS for TROCD. METHODS: We used a Markov model to estimate the cost-effectiveness of DBS compared to conventional treatment for TROCD with a 10-year time horizon. Published data were used to estimate the rates of treatment response and complications. Costs were calculated from the perspective of the third-party payer. Data on quality of life were obtained from a literature review and a survey of OCD patients. We applied the model separately to Korea and the United Kingdom (UK) to enhance the validity. RESULTS: Base-case analysis showed an incremental cost-effectiveness ratio of US$37,865 per quality-adjusted life-year in Korea and US$34,462 per quality-adjusted life-year in the UK. According to the World Health Organization's criteria, DBS for TROCD was "cost-effective" in Korea (<3x GDP per capita) and "highly cost-effective" in the UK (

[Psychiatry and psychiatric patients : A study of the adherence after psychiatric inpatient treatment at the department of psychiatry and psychotherapy at the Clinicum Klagenfurt am Wörthersee.] / Die Psychiatrie und ihre PatientInnen : Eine Studie zur Adhärenz nach Entlassung aus der Abteilung für Psychiatrie und Psychotherapie am Klinikum Klagenfurt am Wörthersee.

BACKGROUND: Based on the data of an analysis of costs of psychopharmacological treatment by the Austrian Rechnungshof in 2011, which also revealed remarkable differences between Salzburg and Carinthia (federal states of Austria), a panel of experts discussed the potential causes. A consequence was the following prospective study, which took place at the department of psychiatry and psychotherapy in Klagenfurt/Carinthia. METHODS: The aim in this mirror design study was to analize the data of psychopharmacologic treatment, epidemiological data of the treated patients (N = 230) and utilization of healthcare ressources such as contacts to psychiatrists or practicioners after discharge. RESULTS: We could show a high adherence concerning the redeem of the prescriptions, a low proportion of generics, and a very low rate of contacts to psychiatrists contrasting contacts to practitioners. CONCLUSIONS: Beneath that in the sense of descriptive epidemiology the data help to characterize adherence behavior after discharge and details of in- and outdoor treatment.

Cost-Utility of Stepped Care Targeting Psychological Distress in Patients With Head and Neck or Lung Cancer.

Purpose A stepped care (SC) program in which an effective yet least resource-intensive treatment is delivered to patients first and followed, when necessary, by more resource-intensive treatments was found to be effective in improving distress levels of patients with head and neck cancer or lung cancer. Information on the value of this program for its cost is now called for. Therefore, this study aimed to assess the cost-utility of the SC program compared with care-as-usual (CAU) in patients with head and neck cancer or lung cancer who have psychological distress. Patients and Methods In total, 156 patients were randomly assigned to SC or CAU. Intervention costs, direct medical costs, direct nonmedical costs, productivity losses, and health-related quality-of-life data during the intervention or control period and 12 months of follow-up were calculated by using Trimbos and Institute of Medical Technology Assessment Cost Questionnaire for Psychiatry, Productivity and Disease Questionnaire, and EuroQol-5 Dimension measures and data from the hospital information system. The SC program's value for the cost was investigated by comparing mean cumulative costs and quality-adjusted life years (QALYs). Results After imputation of missing data, mean cumulative costs were -€3,950 (95% CI, -€8,158 to -€190) lower, and mean number of QALYs was 0.116 (95% CI, 0.005 to 0.227) higher in the intervention group compared with the control group. The intervention group had a probability of 96% that cumulative QALYs were higher and cumulative costs were lower than in the control group. Four additional analyses were conducted to assess the robustness of this finding, and they found that the intervention group had a probability of 84% to 98% that cumulative QALYs were higher and a probability of 91% to 99% that costs were lower than in the control group. Conclusion SC is highly likely to be cost-effective; the number of QALYs was higher and cumulative costs were lower for SC compared with CAU.

Legal high industry business and lobbying strategies under a legal market for new psychoactive substances (NPS, 'legal highs') in New Zealand.

BACKGROUND: The establishment of a regulated legal market for new psychoactive substances (NPS, 'legal highs') under New Zealand's Psychoactive Substances Act (PSA) 2013 created a new commercial sector for psychoactive products, previously limited to alcohol and tobacco. AIM: To explore how the newly-recognised 'legal high' industry (LHI) viewed and responded to the changing regulatory and market environment. METHODS: In-depth interviews with six key informants (KI) from the LHI: a leading entrepreneur, chemist, industry spokesperson, retailer, product buyer and a researcher commissioned by the LHI - were conducted, transcribed and analysed thematically. Formative work for the study included review of official LHI documents (websites, public submissions, self-regulation documents). RESULTS: The LHI stakeholders espoused an idealistic mission of shifting recreational users of alcohol, tobacco and illegal drugs towards "safer alternatives". Passage of the PSA was viewed as a success after years of lobbying led by pioneering LHI actors. The growth and professionalisation of the LHI resulted in an increasingly commercial market which challenged idealistic views of the original operators. LHI KI reported the targeting of young and low income customers, price cutting and increasing the strength of products as business strategies. Attempts by the LHI to self-regulate did not prevent escalation in the strength of products and fall in retail prices. The LHI reported outsourcing of manufacturing and exporting of their products to other countries, demonstrating an international business model. CONCLUSION: There was a tension between profit and idealistic motivations within the LHI and this increased as the sector became more commercialised. While the LHI distanced itself from both alcohol and tobacco, they reported the use of similar marketing, business and political lobbying strategies. Rules for engagement with new 'addictive consumption industries' are required to clarify the role they are permitted to play in the development of regulatory regimes for new psychoactive substances.

[Medication review in the mental health care service: experiences on long-stay units]. / Medicatiebeoordeling in de ggz: praktijkervaring op afdelingen voor langdurig verblijf.

BACKGROUND: Medication review is a recurrent, structured and critical evaluation of pharmacotherapy by patient, physician and pharmacist. The Dutch Health Care Inspectorate considers medication review to be a way of improving the quality and safety of drug treatment. However, little is known about the costs, effectiveness and feasibility of medication review in the practice of mental health care. AIM: To obtain an impression of the costs and benefits of a first medication review in a clinical mental health care setting with chronic patients. METHOD: In 2013, the mental health organisation Yulius enrolled 70 hospitalised chronic patients for a first medication review. A detailed record was kept of the prescribed medication, medication changes, and the time invested. RESULTS: More than half of the proposed changes in medication were eventually implemented; 20% of these changes were made during a planned evaluation after three months. The number of drugs prescribed decreased after medication review; the reduction applied more often to somatic medication than to psychotropic medication. Costs relating to medication reviews seemed to be at least in balance with the benefits. CONCLUSION: In the group of patients with severe mental disorder, medication review seems to provide a good opportunity to assess the rationality of pharmacotherapy in a multidisciplinary approach. The time invested appears to be offset by the benefits of medication review.

The Impact of Psychiatric Practice Guidelines on Medication Costs and Youth Aggression in a Juvenile Justice Residential Treatment Program.

OBJECTIVE: Stakeholders have expressed concern over the appropriate use of psychiatric medications and adequacy of mental health services for youths involved with the juvenile justice system. This study assessed the impact of implementing psychiatric practice guidelines on medication costs and youth aggression in a juvenile justice facility. The study examined whether implementing psychiatric practice guidelines in a facility with an organized psychosocial treatment program would reduce psychiatric medication costs, compared with two other facilities, and whether lower psychotropic medication costs would be associated with increases in youth aggression. METHODS: Administrative data from three state-run juvenile justice facilities were analyzed to determine psychiatric medication costs and rates of youth aggression. Psychiatric practice guidelines that involved screening, shared decision making, psychosocial treatments, medication prescribing, and monitoring of side effects were implemented in only one of the three facilities, with a goal of applying evidence-based psychopharmacology and benefit-risk considerations. RESULTS: Over the ten-year study period (2003-2012), psychiatric medication costs decreased 26% at the facility implementing the psychiatric practice guidelines, whereas costs at the two comparison facilities increased by 104% and 152%. As psychiatric medication costs decreased at the facility implementing the guidelines, youth aggression there did not increase. CONCLUSIONS: Implementing psychiatric practice guidelines in juvenile justice facilities can reduce psychotropic medication costs without an increase in youth aggression. Implementation of the guidelines requires an organized psychosocial treatment program to help deter an inappropriate focus on psychotropic treatments.

[How to assess curative and/or preventive effects of psychotropic drugs?] / Comment évaluer l'effet curatif et/ou préventif des psychotropes ?

Proving the efficacy of a psychotropic drug is a medical, scientific and ethical need. Psychotropic drug development is now a highly complex process, which takes several years and which is very expensive. It involves multiple steps of preclinical and clinical pharmacological refinement and testing. Methodology of studies to prove curative or preventive effect of psychotropic drugs is well codified. Preclinical studies include pharmacokinetic data, toxicology and performance in various animal models of pathology. Clinical phases are centered on randomized controlled double blind trials for demonstrating efficacy and safety/tolerability. This methodology follows strict criteria to avoid bias and to prove internal and external validity of the results. All the results from randomized controlled trials or RCTs lead to different levels of evidence of Evidence-Based Medicine (EBM): gold standard is RCTs while the lowest reference is clinical case or expert opinion. However, it is possible to level criticism at these data issued from RCTs. The main matter is that studies do not reflect the healthcare reality in daily life. For these reasons, a real debate between evaluation of efficacy and effectiveness is acute. Effectiveness refers to the overall effects of psychotropic drugs in naturalistic conditions. Furthermore, analysis of costs and financial benefits are more and more important from social and economic points of view. Official agencies and health insurances look after them very carefully. This article deals with these issues and provides examples using data from the international literature. These examples are drawn from RCTs, naturalistic studies, meta-analysis, pharmaco-economic studies and concern neuroleptics, antipsychotics, antidepressants, and mood-stabilizers.

[Austrian expenditures on psychopharmaceutical drugs between 2006 and 2013]. / Analyse der Ausgaben für Psychopharmaka in Österreich von 2006 bis 2013.

OBJECTIVES: Health costs, which are increasing at a yearly rate of 4 %, represent 11% and thus a large share of Austria's gross domestic product (GDP). High expenditures derive frommental health care costs, including medication. In this article we investigate whether the costs and usage of psychopharmaceutic products in Austria are rising. METHOD: We did a descriptive analysis of the sales figures and number for packaging units of pharmaceutical products of ATC-classes N05 and N06 in all Austrian hospitals, pharmacies and medicine chests for the years 2006-2013. All data were provided free of charge by IMSHealth. RESULTS: The sales volume and number of prescribed packaging units of pharmaceuticals of ATC-classes N05 and N06 increased over the time period in question. In 2013, about 25% more packaging units were being sold than in 2006. Among the two ATC-classes, however, the indication subgroups developed differently. Expenditures increased a total of about 31%within the period of consideration. CONCLUSIONS: The increase in psycho-pharmaceutical sales exceeds the expansion rates of other health expenditures (17.8 %). During the 9 years of observation, 25% more psychopharmaceutical products were sold. This may result from increased prevalence of mental disorders, higher usage or an increment in prescriptions.

Deep pharma: psychiatry, anthropology, and pharmaceutical detox.

Psychiatric medication, or psychotropics, are increasingly prescribed for people of all ages by both psychiatry and primary care doctors for a multitude of mental health and/or behavioral disorders, creating a sharp rise in polypharmacy (i.e., multiple medications). This paper explores the clinical reality of modern psychotropy at the level of the prescribing doctor and clinical exchanges with patients. Part I, Geographies of High Prescribing, documents the types of factors (pharmaceutical-promotional, historical, cultural, etc.) that can shape specific psychotropic landscapes. Ethnographic attention is focused on high prescribing in Japan in the 1990s and more recently in the Upper Peninsula of Michigan, in the US. These examples help to identify factors that have converged over time to produce specific kinds of branded psychotropic profiles in specific locales. Part II, Pharmaceutical Detox, explores a new kind of clinical work being carried out by pharmaceutically conscious doctors, which reduces the number of medications being prescribed to patients while re-diagnosing their mental illnesses. A high-prescribing psychiatrist in southeast Wisconsin is highlighted to illustrate a kind of med-checking taking place at the level of individual patients. These various examples and cases call for a renewed emphasis by anthropology to critically examine the "total efficacies" of modern pharmaceuticals and to continue to disaggregate mental illness categories in the Boasian tradition. This type of detox will require a holistic approach, incorporating emergent fields such as neuroanthropology and other kinds of creative collaborations.

[Effectiveness of Dialectical Behavior Therapy (DBT) in an outpatient clinic for borderline personality disorders - impact of medication use and treatment costs]. / Effektivität der Dialektisch-Behavioralen Therapie (DBT) in der tagesklinischen Behandlung der Borderline-Persönlichkeitsstörung - Bedeutung von Medikation und Behandlungskosten.

OBJECTIVE: Investigation of the clinical effectiveness of dialectical behavioral therapy in a day clinic setting (DBT-DC) for borderline personality disorders (BPD), and impact of medication and daily costs. METHODS: In a prospective, naturalistic, open and uncontrolled design BPD patients were enclosed in a 12-week DBT-DC. This DBT-program was certified by the German network of DBT. We collected data from the Symptom Checklist (SCL-90), the Beck Depression Inventory (BDI) and the Borderline Symptom List 95 (BSL-95) in the first and at the end of the 11th week. The concomitant medication and its changes were described. RESULTS: 31 cases were included (9 drop-outs: 29 %). The average age was 33.3 years (18 - 52, SD = 10.6). 21 females and one male completed the program. There was no relationship between changes of BDI, SCL-90 and BSL-95 scores (p < 0.001) and medication (and its alteration). The BDI scores improved by 50.8 % (p < 0.001), the SCL-90 by 42.9 % (p < 0.01) and the BSL-95 by 48.4 % (p < 0.001). The power was 0.99 (α = 0.05), the effect size was 1.41. In our setting the daily costs showed a reduction of about 6500 € per case compared to an inpatient DBT. Medications played no significant role for improvement. CONCLUSIONS: For the first time a partial remission for BPD patients after 12 weeks has been shown to be achieved in a DBT-DC setting. DBT-DC reduces the primary costs of BPD compared to a specific inpatient therapy.

Polypharmacy reduction in youth in a residential treatment center leads to positive treatment outcomes and significant cost savings.

OBJECTIVE: The purpose of this study was to assess whether polypharmacy regimens can be safely and effectively reduced for youth placed in a residential treatment center, and to assess the cost savings achieved from medication reductions. METHODS: Data were collected for 131 youth ages 11-18, who were admitted to and discharged from a residential treatment center between 2007 and 2011. Six month postdischarge data were available for 51 youth. Data include demographics, admission and discharge medications, place of discharge, and postdischarge stability level. RESULTS: Upon admission, 30 youth were not on medication, at discharge 48 were not; a 60% increase. Mean number of admission medications was 2.16 (SD=0.97) versus 1.55 (SD=0.70) upon discharge. Upon admission, one youth was on five and nine were on four medications. At end-point, only one youth was on four medications. The number of youth needing two or more medications declined by 55%, and the number of those needing three or more declined by 69%. The largest reduction was seen in the number of antipsychotics and antidepressants. Mood stabilizer and antipsychotic combinations declined by 65%. Youth with medication reduction were more likely to be discharged to a less restrictive setting than were youth without medication reduction (72.6% vs. 53.8%), p=0.03. At 6 months postdischarge, of the 51 out of 131 youth with available follow-up data, 71% were doing well. Cost analysis based on discontinued medication by class showed monthly savings of $21,365, or $256,368 yearly. The largest contributor was the reduction in the use of antipsychotics, accounting for $205,332 of the total savings. CONCLUSIONS: Our study indicates that comprehensive treatment can lead to significant reductions in polypharmacy, and positive short- and longer-term treatment outcomes. Judicial prescribing also resulted in significant cost reduction in an already costly healthcare system.

[Psychiatric polypharmacy: hazard through drug-drug-interaction and possibilities for prevention]. / Psychiatrische Polypharmazie: Risiken durch Arzneimittel-wechselwirkungen und mögliche Vermeidungsstrategien.

Psychiatric diseases and comorbidity have increased over the past years. Commonly used psychotropic drugs contain a high risk of drug interactions and adverse drug events (ADE). With a frequency of 10-12% psychotropic drugs are, among all pharmaceuticals, the most common cause of hospitalisation due to ADE. During a hospital stay the application of psychotropic drugs can also lead to adverse drug events--sometimes due to drug interactions. Currently, ADEs and drug interactions are the most frequent cause of death for in-patients (18% of all causes of death) with an overall mortality of 0.95%. As studies have shown, hospitals as well as insurers could save a considerable amount of resources by implementing a system with on-ward pharmacists, hereby reducing ADE and re-hospitalisation rates. In recent studies a large amount of current ADEs were rated as preventable. Patient impairment due to ADE is leading to an increase in liability cases with an expected 5% increase of compensation payments in 2011. To evaluate these ADE-related cases, a pharmaceutical assessment should be included in the expert trials, especially since a lack of awareness of medication errors is prevalent. When aiming towards a successful drug therapy, physicians must also consider that cheaper substances may often have an unfavourable drug interaction profile.

Reducing inappropriate, anticholinergic and psychotropic drugs among older residents in assisted living facilities: study protocol for a randomized controlled trial.

BACKGROUND: Use of inappropriate drugs is common among institutionalized older people. Rigorous trials investigating the effect of the education of staff in institutionalized settings on the harm related to older people's drug treatment are still scarce. The aim of this trial is to investigate whether training professionals in assisted living facilities reduces the use of inappropriate drugs among residents and has an effect on residents' quality of life and use of health services. METHODS AND DESIGN: During years 2011 and 2012, a sample of residents in assisted living facilities in Helsinki (approximately 212) will be recruited, having offered to participate in a trial aiming to reduce their harmful drugs. Their wards will be randomized into two arms: one, those in which staff will be trained in two half-day sessions, including case studies to identify inappropriate, anticholinergic and psychotropic drugs among their residents, and two, a control group with usual care procedures and delayed training. The intervention wards will have an appointed nurse who will be responsible for taking care of the medication of the residents on her ward, and taking any problems to the consulting doctor, who will be responsible for the overall care of the patient. The trial will last for twelve months, the assessment time points will be zero, six and twelve months. The primary outcomes will be the proportion of persons using inappropriate, anticholinergic, or more than two psychotropic drugs, and the change in the mean number of inappropriate, anticholinergic and psychotropic drugs among residents. Secondary endpoints will be, for example, the change in the mean number of drugs, the proportion of residents having significant drug-drug interactions, residents' health-related quality of life (HRQOL) according to the 15D instrument, cognition according to verbal fluency and clock-drawing tests and the use and cost of health services, especially hospitalizations. DISCUSSION: To our knowledge, this is the first large-scale randomized trial exploring whether relatively light intervention, that is, staff training, will have an effect on reducing harmful drugs and improving QOL among institutionalized older people. TRIAL REGISTRATION: ACTRN12611001078943.

Are prescribing doctors sensitive to the price that their patients have to pay in the Spanish National Health System?

BACKGROUND: This study aims to design an empirical test on the sensitivity of the prescribing doctors to the price afforded for the patient, and to apply it to the population data of primary care dispensations for cardiovascular disease and mental illness in the Spanish National Health System (NHS). Implications for drug policies are discussed. METHODS: We used population data of 17 therapeutic groups of cardiovascular and mental illness drugs aggregated by health areas to obtain 1424 observations ((8 cardiovascular groups * 70 areas) + (9 psychotropics groups * 96 areas)). All drugs are free for pensioners. For non-pensioner patients 10 of the 17 therapeutic groups have a reduced copayment (RC) status of only 10% of the price with a ceiling of €2.64 per pack, while the remaining 7 groups have a full copayment (FC) rate of 40%. Differences in the average price among dispensations for pensioners and non-pensioners were modelled with multilevel regression models to test the following hypothesis: 1) in FC drugs there is a significant positive difference between the average prices of drugs prescribed to pensioners and non-pensioners; 2) in RC drugs there is no significant price differential between pensioner and non-pensioner patients; 3) the price differential of FC drugs prescribed to pensioners and non-pensioners is greater the higher the price of the drugs. RESULTS: The average monthly price of dispensations to pensioners and non-pensioners does not differ for RC drugs, but for FC drugs pensioners get more expensive dispensations than non-pensioners (estimated difference of €9.74 by DDD and month). There is a positive and significant effect of the drug price on the differential price between pensioners and non-pensioners. For FC drugs, each additional euro of the drug price increases the differential by nearly half a euro (0.492). We did not find any significant differences in the intensity of the price effect among FC therapeutic groups. CONCLUSIONS: Doctors working in the Spanish NHS seem to be sensitive to the price that can be afforded by patients when they fill in prescriptions, although alternative hypothesis could also explain the results found.