The Increasing Adoption of Out-of-Pocket Cost Caps: Benefits, Unintended Consequences, and Policy Opportunities.

This Viewpoint discusses potential benefits and unintended consequences of out-of-pocket cost caps in Medicare and the employer-sponsored health insurance market and provides suggested policy opportunities to address shortcomings.

Cost-Sharing Increase, Medication Adherence, and Hospitalizations in Schizophrenia Patients: A Natural Experiment.

Increases in medication cost-sharing rates remain a controversial system-wide cost-containment measure for chronic mental health patients. The objective was to investigate the effects of cost-sharing increases on adherence to prescribed antipsychotic medication and psychiatric hospitalizations among patients with schizophrenia. In July 2012, a Spanish National Law raised the cost-sharing rate from 0 to 10% for pensioner outpatient medication while cost-sharing remained at 0% for other socioeconomic groups. To estimate the effects of the reform, we analyzed the prevalent adult schizophrenic population of Valencia, Spain, followed up 1 year before and after the Law took effect. We used a quasi-experimental design with a patient fixed-effects difference-in-differences regression to evaluate the reform effects on antipsychotic medication adherence, prescription, and hospitalization rates. A total of 5,672 included patients were exposed to the reform, whereas 5,545 were not. There were no differences in adherence, prescription, or hospitalization rates between exposed and nonexposed patients prior to its implementation. The odds ratio of exposed patients remaining adherent to issued prescriptions after the reform took effect were 0.70 99% confidence interval (CI 0.66-0.75), in relation to the nonexposed group. Additionally, the reform was associated with a reduction in exposure to antipsychotic medication (odds ratio (OR) 0.85, 99%CI 0.83-0.88) and an increase in hospitalization risk (OR 1.13, 99% CI 1.05-1.23) during the first year after implementation. Policies raising the cost-sharing rate of medication for patients with schizophrenia are simultaneously associated with unintended effects. We report decreases in antipsychotic exposure and increases in hospitalization rates that lasted for 1 year after follow-up.

An investigation of health insurance policy and behavior in a virtual environment.

We introduce a new experimental approach to measuring the effects of health insurance policy alternatives on behavior and health outcomes over the life course. In a virtual environment with multi-period lives, subjects earn virtual income and allocate spending, to maximize utility, which is converted into cash payment. We compare behavior across age, income and insurance plans-one priced according to an individual's expected cost and the other uniformly priced through employer-implemented cost sharing. We find that 1) subjects in the employer-implemented plan purchased insurance at higher rates; 2) the employer-based plan reduced differences due to income and age; 3) subjects in the actuarial plan engaged in more health-promoting behaviors, but still below optimal levels, and did save at the level required, so did realize the full benefits of the plan. Subjects had more difficulty optimizing choices in the Actuarial treatment, because it required more long term planning and evaluating benefits that compounded over time. Contrary, to model predictions, the actuarial priced insurance plan did not increase utility relative to the employer-based plan.

Addressing Insulin Access and Affordability: An Endocrine Society Position Statement.

Rising costs have made access to affordable insulin far more difficult for people with diabetes, especially low-income individuals, those on high deductible health plans, beneficiaries using Medicare Part B to cover insulin delivered via pump, Medicare beneficiaries in the Part D donut hole, and those who turn 26 and must transition from their parents' insurance, to manage their diabetes and avoid unnecessary complications and hospitalizations. For many patients with diabetes, insulin is a life-saving medication. Policymakers should immediately address drivers of rising insulin prices and implement solutions that would reduce high out-of-pocket expenditures for patients. The Endocrine Society recommends policy options to expand access to lower cost insulin in this paper.

Power of 1 Malaysian Ringgit: A Low-Cost Prescription Cost-Sharing Model in Malaysia.

OBJECTIVES: To calculate the total revenue under a hypothetical 1 Malaysian Ringgit (MYR) prescription cost sharing model in government healthcare facilities in Pahang, Malaysia. METHODS: A cross-sectional study was conducted at outpatient pharmacy in all government healthcare facilities in Pahang from year 2013 to 2017. Each dispensed medication was calculated as 1 MYR and contributed to the total revenue. RESULTS: A total of 11 hospitals and 81 health clinics were recruited into the study. A hospital could generate 0.311 million MYR per year, and a district health department could generate 0.623 million MYR per year, giving a total of 10.268 million MYR revenue every year in Pahang, Malaysia. Under the prescription medicines cost sharing scheme, it was shown that an average of 9.4% of the total pharmaceutical spending could be recovered. The recovery percentage was approximately fourfold higher in health clinics (16.5%-21.7%) when compared with that in hospitals (4.3%-5.2%). CONCLUSION: An estimated 10 million MYR or 10% from the total Ministry of Health pharmaceutical spending could be collected under the proposed 1 MYR prescription cost sharing model.

The Economic Burden of Out-of-Pocket Expenses for Plastic Surgery Procedures.

BACKGROUND: Health insurance reimbursement structure has evolved, with patients becoming increasingly responsible for their health care costs through rising out-of-pocket expenses. High levels of cost sharing can lead to delays in access to care, influence treatment decisions, and cause financial distress for patients. METHODS: Patients undergoing the most common outpatient reconstructive plastic surgery operations were identified using Truven MarketScan databases from 2009 to 2017. Total cost of the surgery paid to the insurer and out-of-pocket expenses, including deductible, copayment, and coinsurance, were calculated. Multivariable generalized linear modeling with log link and gamma distribution was used to predict adjusted total and out-of-pocket expenses. All costs were inflation-adjusted to 2017 dollars. RESULTS: The authors evaluated 3,165,913 outpatient plastic and reconstructive surgical procedures between 2009 and 2017. From 2009 to 2017, total costs had a significant increase of 25 percent, and out-of-pocket expenses had a significant increase of 54 percent. Using generalized linear modeling, procedures performed in outpatient hospitals conferred an additional $1999 in total costs (95 percent CI, $1978 to $2020) and $259 in out-of-pocket expenses (95 percent CI, $254 to $264) compared with office procedures. Ambulatory surgical center procedures conferred an additional $1698 in total costs (95 percent CI, $1677 to $1718) and $279 in out-of-pocket expenses (95 percent CI, $273 to $285) compared with office procedures. CONCLUSIONS: For outpatient plastic surgery procedures, out-of-pocket expenses are increasing at a faster rate than total costs, which may have implications for access to care and timing of surgery. Providers should realize the increasing burden of out-of-pocket expenses and the effect of surgical location on patients' costs when possible.

Out-Of-Pocket Spending For Maternity Care Among Women With Employer-Based Insurance, 2008-15.

The Affordable Care Act (ACA) requires employer-based insurance plans to cover maternity services, but plans are allowed to impose cost sharing such as copayments and deductibles for these services. This study aimed to evaluate trends in cost sharing for maternity care among working women in employer-based plans, before and after the ACA. Our data indicate that between 2008 and 2015, average out-of-pocket spending for maternity care rose among women with employer-based insurance. This increase was largely driven by increased spending among women with deductibles. When we controlled for potential confounders, we found that out-of-pocket spending was higher for lower-income working women in 2008-13, but disparities disappeared in 2014-15 because of a continued rise in spending among higher-income working women. Policies that aim to lower out-of-pocket spending for maternity care could reduce a significant financial burden on families.

Trends In Coverage For Disease-Modifying Therapies For Multiple Sclerosis In Medicare Part D.

The high cost of multiple sclerosis (MS) disease-modifying therapies can negatively affect access for patients through increased payer restrictions and higher out-of-pocket spending. Our objective was to describe changes in pharmacy benefit coverage and cost-sharing amounts for MS disease-modifying therapies in the Medicare Part D program, using enrollment-weighted Prescription Drug Plan Formulary files for the period 2007-16. Among therapies available throughout the study period, the rate of prior authorization use increased from 61-66 percent of plans to 84-90 percent. The share of plans with at least one therapy available without limitations declined from 39 percent to 17 percent. The projected cumulative out-of-pocket spending for 2019 was $6,894. The therapy with the highest out-of-pocket spending was generic glatiramer acetate. Policy makers need to consider both access restrictions and a growing cost-sharing burden as potential consequences of high and rising drug prices for people with MS.

Novel Type 2 Diabetes Medication Access and Effect of Patient Cost Sharing.

BACKGROUND: Although drug formulary restrictions may reduce use of prescription medication and pharmacy costs, the effect of patient cost sharing on medication adherence and health care utilization and cost is unclear. OBJECTIVE: To evaluate the relationship between patient cost sharing for novel type 2 diabetes mellitus (T2DM) medications and medication adherence, persistence, and health care utilization and cost. METHODS: This retrospective study used medical and pharmacy claims linked to pharmacy benefit plan design data. Patients with T2DM were identified via ICD-9-CM codes (medical claims), outpatient prescription fills (pharmacy claims), and pharmacy benefit design information. Patients with T2DM treated with novel T2DM medications (DPP4 or GLP-1) were enrolled in plans with fixed or coinsurance medication copayment structures and followed for 12-48 months. Endpoints included medication persistence and adherence and total all-cause health care cost. Multivariable regression analysis estimated the effect of benefit design parameters, adjusting for baseline patient characteristics. RESULTS: The integrated database included 36,475 patients with T2DM. The majority (83.1%) had fixed copayment plans, and 3-tier plans were common (93.1%). Higher third-tier copayment was associated with poorer medication adherence and persistence but not total health care cost during follow-up. A $10 higher third-tier copayment was associated with 11% greater risk of novel T2DM medication discontinuation and 3% lower adherence. A comparison of patients with fixed versus coinsurance plans found that fixed plans were associated with higher adjusted persistence and total all-cause health care costs. CONCLUSIONS: Higher medication copayment amounts were associated with lower patient medication adherence and persistence in T2DM but not total health care costs, as health plan costs decreased while patient out-of-pocket costs increased. We observed higher total all-cause health care costs among T2DM patients with a fixed copay (vs. coinsurance) pharmacy benefit. Additional research incorporating plan design information is needed to further examine this finding. DISCLOSURES: This study was funded by Janssen Scientific Affairs, which was involved in study design, interpretation of data, editing manuscript content, and had final approval of the manuscript before submission. Lopez and Bookhart are employed by Janssen Scientific Affairs. At the time of this study, Henk was employed by Optum HEOR, which was contracted by Janssen to conduct this study. Portions of this study were presented at the 21st Annual International Meeting, ISPOR; May 21-25, 2016; in Washington, DC.

Financing health care in Tunisia. Current state of health care expenditure and socialization prospects, on the road to Universal Health Coverage.

CONTEXT: As part of its strategy of Universal Health Coverage (UHC), Tunisia has calculated, after its revolution, its Health Accounts (HA), in a standardized and interdepartmental way. OBJECTIVES: Describe the current structure of care financing in Tunisia, through the HA reports, from 2012 to 2014, and assess its compliance with the principles of socialization of health insurance. METHODS: Crude data on health care expenditures were collected by a multi-departmental group that is responsible for calculating health accounts, using a methodology developed by WHO. On the basis of these data, a dozen of indicators that serve to monitor the financing of care, were determined, especially the proportion of public care expenditure (state and insurance), the proportion of direct payments of households in total care expenditure. and the share of expenses of the National Diseases Insurance Fund (CNAM) in the private sector. RESULTS: During the 2012-2014 trienniums, the total health expenditure represented 7% of GDP. Public expenditure on health care did not exceed 57% of the total health expenditure, which is 4% of GDP. Households paid directly, from their pockets, 39% of current care expenditures. About half of the expenses of the CNAM, was released for the reimbursement of consultations, explorations and hospitalizations in private clinics and medical needs (drugs and medical material) in private pharmacies. CONCLUSION: The financing of the post-revolution care system in Tunisia was characterized by a dangerous triad for its survival, performance and equity: excessive spending compared to the country's growth, a very high contribution of households exceeding the cutoff of "catastrophic" spending, and a marked shift in the social policy of the CNAM, in favor of the private sector. This profile, proof of low socialization of healthcare financing, would be a limiting factor in the implementation of the CSU strategy in Tunisia.

Impact of consumer copayments for subsidised medicines on health services use and outcomes: a protocol using linked administrative data from Western Australia.

INTRODUCTION: Across the world, health systems are adopting approaches to manage rising healthcare costs. One common strategy is a medication copayments scheme where consumers make a contribution (copayment) towards the cost of their dispensed medicines, with remaining costs subsidised by the health insurance service, which in Australia is the Federal Government.In Australia, copayments have tended to increase in proportion to inflation, but in January 2005, the copayment increased substantially more than inflation. Results from aggregated dispensing data showed that this increase led to a significant decrease in the use of several medicines. The aim of this study is to determine the demographic and clinical characteristics of individuals ceasing or reducing statin medication use following the January 2005 Pharmaceutical Benefit Scheme (PBS) copayment increase and the effects on their health outcomes. METHODS AND ANALYSIS: This whole-of-population study comprises a series of retrospective, observational investigations using linked administrative health data on a cohort of West Australians (WA) who had at least one statin dispensed between 1 May 2002 and 30 June 2010. Individual-level data on the use of pharmaceuticals, general practitioner (GP) visits, hospitalisations and death are used.This study will identify patients who were stable users of statin medication in 2004 with follow-up commencing from 2005 onwards. Subgroups determined by change in adherence levels of statin medication from 2004 to 2005 will be classified as continuation, reduction or cessation of statin therapy and explored for differences in health outcomes and health service utilisation after the 2005 copayment change. ETHICS AND DISSEMINATION: Ethics approvals have been obtained from the Western Australian Department of Health (#2007/33), University of Western Australia (RA/4/1/1775) and University of Notre Dame (0 14 167F). Outputs from the findings will be published in peer reviewed journals designed for a policy audience and presented at state, national and international conferences.

El copago de dependencia en España a partir de la reforma estructural de 2012 / The co-payment of the dependence from the structural reform of 2012 in Spain

Objetivo: Estimar el coste de la dependencia y su financiación. En particular, determinar el copago de los usuarios tras la modificación introducida por la Resolución de 13 de julio de 2012, según el grado de dependencia y la comunidad autónoma de residencia. Métodos: Se estimó el grado de dependencia a partir de la Encuesta sobre Discapacidades, Autonomía Personal y situaciones de Dependencia de 2008. El coste de la dependencia por grado y comunidad autónoma se calculó a partir de la información del Sistema para la Autonomía y Atención a la Dependencia. El copago se calculó a partir de la renta de las personas dependientes. La valoración monetaria de los servicios y la aportación de los usuarios se hizo de acuerdo a la normativa de 2012 y con indicadores de referencia comunes para todo el territorio nacional. Resultados: El coste total estimado en 2012 es de 10.598,8 millones de euros (1,03% del producto interior bruto), y son Andalucía, la Comunidad Valenciana y Cataluña las que mayores cuantías presentan. El porcentaje del copago medio nacional por usuario es del 53,54%, con diferencias por grados y comunidades autónomas, aunque en general los usuarios financian más de la mitad del coste de las prestaciones en todas ellas. Conclusiones: El cambio legislativo ha supuesto que el copago sea superior al tercio inicial establecido en la Ley y a los copagos anteriores a 2012, que eran en torno al 20%. Si a ello se añaden las diferencias por comunidades autónomas, sería conveniente reflexionar acerca de la desigual aplicación de la Ley (AU)

Objective: The objective of this piece of work is to establish the cost of dependency and the cost of financing it. Specifically, we will determine the cost of co-payment for individual users following the modification introduced by the 13th of July 2012 Resolution as well as its allocation by the autonomous regions. Methods: The degree and level of dependency was established using the Survey on Disability, Personal Autonomy and Dependency Situations, 2008. The cost of dependency according to degree and level and autonomous regions was established with information from the System for Personal Autonomy and Care of Dependent Persons. The co-payment was established according to applicants’ purchasing power. The rating of these services, and the contribution of individual users were done in agreement with 2012 legislation and with common indicators and benchmarks for the whole national territory. Results: The total estimated cost is 10,598.8 million euros (1.03% of GDP), and Andalusia, the Valencian Community and Catalonia are those regions with the greatest costs. The average national co-payment per individual user is 53.54%, with differences due to degrees and levels of disability and autonomous regions, although, generally speaking, all of the users fund more than half of the care they receive. Conclusions: This change in legislation has meant that co-payment is higher than the 33% established by this law and that co-payments prior to 2012 were about 20%. If we add to this the differences in autonomous regions, it would be useful to reflect on the uneven application of the law (AU)

Want to fight chronic disease? Stop subsidizing drug companies.

Healthcare systems have made great strides in recent years in learning how to use their medical records and claims data to identify patients at high risk of contracting chronic diseases such as diabetes. Unfortunately, under fee-for-service medicine, doing something with that information is rarely a smart move financially.

Affordable Care Act's Mandate Eliminating Contraceptive Cost Sharing Influenced Choices Of Women With Employer Coverage.

Patient cost sharing for contraceptive prescriptions was eliminated for certain insurance plans as part of the Affordable Care Act. We examined the impact of this change on women's patterns of choosing prescription contraceptive methods. Using claims data for a sample of midwestern women ages 18-46 with employer-sponsored coverage, we examined the contraceptive choices made by women in employer groups whose coverage complied with the mandate, compared to the choices of women in groups whose coverage did not comply. We found that the reduction in cost sharing was associated with a 2.3-percentage-point increase in the choice of any prescription contraceptive, relative to the 30 percent rate of choosing prescription contraceptives before the change in cost sharing. A disproportionate share of this increase came from increased selection of long-term contraception methods. Thus, the removal of cost as a barrier seems to be an important factor in contraceptive choice, and our findings about long-term methods may have implications for rates of unintended pregnancy that require further study.