The effect of a change in co-payment on prescription drug demand in a National Health System: The case of 15 drug families by price elasticity of demand.

OBJECTIVES: To test the heterogeneity of the effect of a change in pharmaceutical cost-sharing by therapeutic groups in a Spanish region. METHODS: Data: random sample (provided by the Canary Islands Health Service) of 40,471 people covered by the Spanish National Health System (SNHS) in the Canary Islands. The database includes individualised monthly-dispensed medications (prescribed by the SNHS) from one year before (August 2011) to one year after (June 2013) the Royal Decree Law 16/2012 (RDL 16/2012). Sample: two intervention groups (low-income pensioners and middle-income working population) and one control group (low-income working population). Empirical model: quasi-experimental difference-in-differences design to study the change in consumption (measured in number of monthly Defined Daily Dose (DDDs) per individual) among 13 therapeutic groups. The policy break indicator (three-level categorical variable) tested the existence of stockpiling between the reform's announcement and its implementation. We ran 16 linear regression models (general, by therapeutic groups and by comorbidities) that considered whether the exclusion of some drugs from public provision impacted on consumption more than the co-payment increase. RESULTS: General: Reduction (-13.04) in consumption after the reform's implementation, which was fully compensated by a previous increase (16.60 i.e., stockpiling) among low-income pensioners. The middle-income working population maintained its trend of increasing consumption. Therapeutic groups: Reductions in consumption after the reform's implementation among low-income pensioners in 7 of the 13 groups, which were fully compensated for by a previous increase (i.e., stockpiling) in 4 groups and partially compensated for in the remaining 3. The analysis without the excluded medicines provided fewer negative coefficients. Comorbidities: Reduction in consumption that was only slightly compensated for by a previous increase (i.e., stockpiling). CONCLUSIONS: The negative impact of cost-sharing produced, among low-income pensioners, a risk of loss of adherence to treatments, which could deteriorate the health status of individuals, especially among pensioners within the most inelastic therapeutic groups (associated with chronic diseases) and patients with comorbidities (also, associated with chronic diseases). Notwithstanding the above, this risk was more related to the exclusion of some drugs from provision than to the cost-sharing increase.

Impact of a pharmacy benefit change on new use of mail order pharmacy among diabetes patients: the Diabetes Study of Northern California (DISTANCE).

OBJECTIVE: To assess the impact of a pharmacy benefit change on mail order pharmacy (MOP) uptake. DATA SOURCES/STUDY SETTING: Race-stratified, random sample of diabetes patients in an integrated health care delivery system. STUDY DESIGN: In this natural experiment, we studied the impact of a pharmacy benefit change that conditionally discounted medications if patients used MOP and prepaid two copayments. We compared MOP uptake among those exposed to the benefit change (n = 2,442) and the reference group with no benefit change (n = 8,148), and estimated differential MOP uptake across social strata using a difference-in-differences framework. DATA COLLECTION/EXTRACTION METHODS: Ascertained MOP uptake (initiation among previous nonusers). PRINCIPAL FINDINGS: Thirty percent of patients started using MOP after receiving the benefit change versus 9 percent uptake among the reference group (p < .0001). After adjustment, there was a 26 percentage point greater MOP uptake (benefit change effect). This benefit change effect was significantly smaller among patients with inadequate health literacy (15 percent less), limited English proficiency (14 percent less), and among Latinos and Asians (24 and 16 percent less compared to Caucasians). CONCLUSIONS: Conditionally discounting medications delivered by MOP effectively stimulated MOP uptake overall, but it unintentionally widened previously existing social gaps in MOP use because it stimulated less MOP uptake in vulnerable populations.

[Co-payment for public health care services--public opinion survey]. / Wspólplacenie za uslugi medyczne--badanie opinii spolecznej.

One of the solutions aimed at improving the functioning of the healthcare system in Poland is to introduce patients' co-payment for public healthcare services. In all countries where the healthcare system is at a high level there already exists a co-payment system and it is regarded by many specialists as a necessary and indispensable condition for the proper functioning of healthcare. The aim of this study was to show respondents' attitudes and opinions regarding the proposal of introduction co-payments as and additional form of financing medical care. The questionnaire survey covered a group of 2,409 persons (50.7% men and 49.3% women). Most respondents, despite the overall rising dissatisfaction with the quality and availability of medical services do not see the need for co-payments. The opinion about the implementation of co-payments. The opinion about the implementation of co-payments depends on many factors, to the most important belong age, education, place of residence and income. More often, the co-payments is in favour of young people in good health condition, who live in big cities, having a university degree and determining their financial situation as good. Before the introduction of co-payment - certain social groups, which would be exempt from additional fees, should be specified. To the highest costs that patients are able to carry belong: paying for a home visit of family doctor or specialist, for surgical procedures, and for complex tests performed during the hospital stay (including computed tomography, magnetic resonance imaging).

The introduction of a targeted user-pays approach to funding high-level residential aged care in Australia: an empirical investigation of the impact on price.

In response to predictions that population ageing will increase government spending over the coming decades, in 1997-98, the Australian Government introduced means-tested income fees and accommodation charges for those admitted to nursing homes with income and assets above set threshold levels. Immediately prior, all residents paid the same price for their care and were not required to contribute towards the cost of their accommodation. In addition, in relation to those eligible to pay a higher price, the Government reduced its subsidisation of the cost of their care. The Government anticipated that the initiative would more equitably share the cost of age-related services across the public and private sectors, and result in some cost savings for itself. The purpose of this study is to assess the impact of the policy on the average price paid by residents. The findings suggest that the policy may have contributed to an increase in the average price paid, but statistical evidence is limited due to a number of data issues. Results also indicate that the rate of increase in the price was greater after the Residential Aged Care Structural Reform package was introduced. The study contributes to the economic analysis of the sector by evaluating time series estimates of prices paid by residents since the early 1970s.

Effects of benefit design change across 5 disease states.

OBJECTIVE: To assess the effects of benefit design change (BDC) on medication adherence and persistence (including switch in therapy), drug costs, and total healthcare costs. STUDY DESIGN: A retrospective study was performed using administrative claims data from an integrated healthcare system between January 2001 and December 2002. METHODS: Continuously enrolled patients in 2001 and 2002 with allergic rhinitis, asthma, diabetes mellitus, hypertension, or osteoarthritis belonged to employer groups with or without a pharmacy BDC as of January 1, 2002. Prescription status (same, switch, or discontinue), adherence among patients receiving therapy, and differences in drug costs and total healthcare costs for each disease state were measured between groups. Bivariate and multivariate statistics were used to test differences in outcomes between groups. RESULTS: Compared with the group without BDC, the proportion of patients who discontinued drug therapy was significantly greater in the BDC group among those with allergic rhinitis (67% vs 54%), asthma (66% vs 50%), osteoarthritis (61% vs 36%), and hypertension (39% vs 18%) (P < .05 for all). Medication compliance was not affected by BDC. The year-to-year pharmacy costs per patient in the BDC group decreased $305 for patients with osteoarthritis (P < .001) and $95 for patients with allergic rhinitis (P = .03). There was no significant effect on overall healthcare costs in any disease state during the year following the BDC. CONCLUSION: A pharmacy BDC may result in decreased pharmacy costs, with no effect on overall healthcare costs within 1 year for patients with allergic rhinitis, asthma, hypertension, or osteoarthritis.

Attention-deficit/hyperactivity disorder in children: excess costs before and after initial diagnosis and treatment cost differences by ethnicity.

OBJECTIVES: To estimate the excess costs for children in the years surrounding initial diagnosis of attention-deficit/hyperactivity disorder (ADHD) and to estimate differences in treatment costs by ethnicity. DESIGN: We identified children diagnosed with ADHD and estimated their health service costs in the 2 years before and 2 years after initial diagnosis of ADHD. Costs were compared with those for children without ADHD. We adjusted for age, sex, ethnicity, pharmacy co-pay, estimated family income, coexisting mental health disorders, and chronic medical conditions. SETTING: Nonprofit, integrated health care delivery system in northern California from January 1, 1996, to December 31, 2004. PARTICIPANTS: Children aged 2 to 10 years with (n = 3122) and without (n = 15 899) ADHD. Main Exposure Attention-deficit/hyperactivity disorder. MAIN OUTCOME MEASURES: Health care costs and use in the years before and after initial ADHD diagnosis as well as costs of ADHD-related services. RESULTS: Compared with children without ADHD, children with ADHD had mean costs that were $488 more in the second year before their ADHD diagnosis, $678 more in the year before their diagnosis, $1328 more in the year after their diagnosis, and $1040 more in the second year after their diagnosis. Asian Americans diagnosed with ADHD had lower total ADHD-related mean costs per year than white Americans diagnosed with ADHD ($221 lower), and Asian Americans, African Americans, and Hispanic Americans all had lower ADHD-related pharmacy mean costs than white Americans ($95, $63, and $77 lower, respectively). CONCLUSIONS: Children with ADHD use significantly more health services before and after their diagnosis than children without ADHD. Among children diagnosed with ADHD, nonwhite Americans (especially Asian Americans) use fewer ADHD-related services than white Americans.

Chiropractic and medical costs of low back care.

This study compares health insurance payments and patient utilization patterns for episodes of care for common lumbar and low back conditions treated by chiropractic and medical providers. Using 2 years of insurance claims data, this study examines 6,183 patients who had episodes with medical or chiropractic first-contact providers. Multiple regression analysis, to control for differences in patient, clinical, and insurance characteristics, indicates that total insurance payments were substantially greater for episodes with a medical first-contact provider. Most of the cost differences were because of higher inpatient payments for such cases. Analysis of recurrent episodes indicates that chiropractic providers retain more patients for subsequent episodes and that patient exposure to a different provider type during early episodes significantly affects retention rates for later episodes. Patients choosing chiropractic and medical care were comparable on measures of severity and in lapse time between episodes. The lower costs for episodes in which chiropractors serve as initial contact providers along with the favorable satisfaction and quality indicators for patients suggest that chiropractic deserves careful consideration in gatekeeper strategies adopted by employers and third-party payers to control health care spending. More research is needed, especially in developing alternative measures of health status and outcomes.