The effect of drug co-payments on utilization and cost of pharmaceuticals in a health maintenance organization. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. Prescription drug utilization following patient co-payment changes in Australia. Analysis of the North Carolina long-term care polypharmacy initiative: a multiple-cohort approach using propensity-score matching for both evaluation and targeting. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. User fees plus quality equals improved access to health care: results of a field experiment in Cameroon. Outcomes of a randomized controlled trial of a clinical pharmacy intervention in 52 nursing homes. Impact of a cost sharing drug insurance plan on drug utilization among individuals receiving social assistance. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care.
This study analyzed how the use and cost of pharmaceuticals varied by level of drug co-payment in a staff model health maintenance organization (HMO). An historical cohort design was used to study changes in drug utilization and drug costs in 19,982 continuously enrolled beneficiaries less than the age of 65. The beneficiaries initially had no drug co-payments, but experienced co-payment rates of $1.50, $3.00, and $3.00 plus other benefit changes during a three-year period. A comparison cohort of 23,164 beneficiaries was selected from the same setting who were subject to no drug co-payment during the same time period. Data on the use and cost of medications were obtained from an automated data system. Adjusted analyses for each time period controlled for age, sex, years in the Group Health Cooperative (GHC), and prior year utilization (or cost). The initial $1.50 drug co-payment was associated with a drop of 10.7% in the number of prescriptions filled relative to change in the comparison cohort. The decrease was greatest for discretionary drugs at each level of co-payment. The implementation of progressively greater levels of co-payments continued to have a significant effect on drug utilization since each co-payment level resulted in an additional reduction in drug utilization; 10.6% with the $3 co-payment and 12.0% when the $3 drug co-payment was combined with other cost-sharing provisions. Co-payments were associated with lower per capita drug costs and higher per prescription unit costs. Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups.
                To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation.
                Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events.
                A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients.
                Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction.
                After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits.
                In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions. In November 1990 major patient co-payment changes were introduced into the Pharmaceutical Benefits Scheme (PBS), which accounts for around 90% of all community prescriptions in Australia. Interrupted time series analyses were performed to assess the impact of these co-payment changes on the prescription levels of defined groups of 'discretionary' and 'essential' drugs for both the general community and for a subgroup comprising elderly returned servicemen and women. While the co-payment changes themselves had a significant immediate effect on lowering the use of both categories of drugs, the effects were substantially larger for the 'discretionary' groups in both cases. Notably there was a clear post-intervention trend for increased prescriptions of 'essential' drugs after the initial decline, which was not evident for the 'discretionary' drugs. The introduction of programmes to compensate high risk groups in Australia may have enabled the co-payment to become a more selective policy instrument than has been shown in other settings. The high cost and undesirable consequences of polypharmacy are well-recognized problems among elderly long-term care (LTC) residents. Despite the implementation of the 1987 Omnibus Budget Reconciliation Act, which requires pharmacist review of drug regimens in this setting, medical and drug costs for LTC residents have continued to increase.
                This study evaluates the North Carolina Long-Term Care Polypharmacy Initiative, a large-scale medication therapy management program (MTMP) that combined drug utilization review activities with drug regimen review techniques.
                This was a prospective records-based study that used a difference-in-difference model with both historical and nonintervention group controls. To ensure equivalence among subjects, propensity scoring was used to match study subjects from participating LTC facilities with comparison subjects from nonparticipating facilities. Residents with interventions were grouped for analysis by intervention type-retrospective only, prospective only, or dual type (residents with both prospective and retrospective interventions)-and by intervention stage-review, recommendation, and drug change-plus an all-inclusive "all types" grouping that aggregated groups by intervention type, for a total of 10 total cohorts.
                In the overall population of 5255 study subjects identified, a US $21.63 per member per month drug-cost savings was observed. Although only 1 of 10 cohorts had a change in the number of drug fills, substantial reductions in 2 of 5 types of drug alerts were observed in all 10 cohorts. A reduction in the relative risk for hospitalization (0.84 [95% CI, 0.71-1.00]) was observed in the cohort of residents receiving a retrospective review.
                This Initiative suggests that an MTMP can be quickly launched in a large number of LTC facility residents to produce monetary drug-cost savings and improved health outcomes. Additionally, the evaluation of this program illustrates the utility of using propensity scoring techniques to target future intervention groups in a cost-effective manner. Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements.
                We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not. The study patients in New Hampshire (n = 411) and a matched comparison cohort in New Jersey (n = 1375) were Medicaid recipients 60 years of age or older who in a base-line year had been taking three or more medications per month, including at least one maintenance drug for certain chronic diseases. Survival (defined as remaining in the community) and time-series analyses were conducted to determine the effect of the reimbursement cap on admissions to hospitals and nursing homes.
                The base-line demographic characteristics of the cohorts were nearly identical. In New Hampshire, the 35 percent decline in the use of study drugs after the cap was applied was associated with an increase in rates of admission to nursing homes; no changes were observed in the comparison cohort (RR = 1.8; 95 percent confidence interval, 1.2 to 2.6). There was no significantly increased risk of hospitalization. Among the patients in New Hampshire who regularly took three or more study medications at base line, the relative risk of admission to a nursing home during the period of the cap was 2.2 (95 percent confidence interval, 1.2 to 4.1), and the risk of hospitalization was 1.2 (95 percent confidence interval, 0.8 to 1.6). When the cap was discontinued after 11 months, the use of medications returned nearly to base-line levels, and the excess risk of admission to a nursing home ceased. In general, the patients who were admitted to nursing homes did not return to the community.
                Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs. Since the Bamako Initiative was launched in 1988, many African countries have embarked on comprehensive primary health care programs relying, at least partially, on revenues generated through user fees to revitalize health care delivery systems. Although these programs contain two critical components, user fees and improved quality, policy debates have tended to focus on the former and disregarded the latter. The purpose of this study is to provide a net assessment of these two components by testing how user fees and improved quality affect health facility utilization among the overall population and specifically among the poorest people. A "pretest-posttest controlled" experiment was conducted in five public health facilities in the Adamaoua province of Cameroon. Three health centers which were to introduce a user fee and quality improvement (i.e. reliable drug supply) policy were selected as "treatment" centers and two comparable facilities not yet phased into this policy were selected as "controls". Two rounds of household surveys were conducted (each to 800 households in 25 villages surrounding the five study sites) to measure the percentage of ill people seeking care at the health center before and after the implementation of the policy. The experiment was tightly controlled by conducting monthly observations at each study site. Results indicate that the probability of using the health center increased significantly for people in the "treatment" areas compared to those in the "control" areas. Travel and time costs involved in seeking alternative sources of care are high; when good quality drugs became available at the local health center, the fee charged for care and treatment represented an effective reduction in the price of care and thus utilization rose. Moreover, contrary to previous studies which have found that the poorest quintile is most hurt by user fees, this study found that probability of the poorest quintile seeking care increases at a rate proportionately greater than the rest of the population. Since the poor are most responsive to price changes, they appear to be benefitting from local availability of drugs more than others. To evaluate whether a year long clinical pharmacy program involving development of professional relationships, nurse education on medication issues, and individualized medication reviews could change drug use, mortality and morbidity in nursing home residents.
                A cluster randomised controlled trial, where an intervention home was matched to three control homes, was used to examine the effect of the clinical pharmacy intervention on resident outcomes. The study involved 905 residents in 13 intervention nursing homes and 2325 residents in 39 control nursing homes in south-east Queensland and north-east New South Wales, Australia. The outcome measures were: continuous drug use data from government prescription subsidy claims, cross-sectional drug use data on prescribed and administered medications, deaths and morbidity indices (hospitalization rates, adverse events and disability indices).
                This intervention resulted in a reduction in drug use with no change in morbidity indices or survival. Differences in nursing home characteristics, as defined by cluster analysis with SUDAAN, negated intervention-related apparent significant improvements in survival. The use of benzodiazepines, nonsteroidal anti-inflammatory drugs, laxatives, histamine H2-receptor antagonists and antacids was significantly reduced in the intervention group, whereas the use of digoxin and diuretics remained similar to controls. Overall, drug use in the intervention group was reduced by 14.8% relative to the controls, equivalent to an annual prescription saving of A64 dollars per resident (approximately 25 pound sterling).
                This intervention improved nursing home resident outcomes related to changes in drug use and drug-related expenditure. The continuing divergence in both drug use and survival at the end of the study suggests that the difference would have been more significant in a larger and longer study, and even more so using additional instruments specific for measuring outcomes related to changes in drug use. A cost-sharing drug insurance plan has been implemented among people receiving social assistance who had previously free access to medications.
                To assess the impact of this drug plan on the use of three classes of medications: inhaled corticosteroids, neuroleptics and anticonvulsants.
                From the computerized drug databases of the Régie de l'assurance maladie du Québec (RAMQ), we selected three random samples of Quebec residents receiving social assistance between August 1992 and June 1997 and aged 64 years or less: 55890 users of inhaled corticosteroids, 29461 users of neuroleptics and 44916 users of anticonvulsants. We also obtained data for individuals privately insured by the Commission de la construction du Québec (control group). Comparison of the monthly consumption of medications before and after the new drug plan was done using time series models.
                For individuals receiving social assistance and using inhaled corticosteroids, we observed a statistically significant decrease of 37% of the monthly consumption for the 11 months following the new drug plan. For neuroleptics and anticonvulsants, we observed a non significant decrease of 9 and 10%, respectively. No decrease in drug consumption was observed in the control group.
                Inhaled corticosteroids was the only class of medications that was found to decrease significantly after the implementation of the drug insurance plan. Adverse drug-related events are common in the elderly, and inappropriate prescribing is a preventable risk factor. Our objective was to determine whether inappropriate prescribing could be reduced when primary care physicians had computer-based access to information on all prescriptions dispensed and automated alerts for potential prescribing problems.
                We randomly assigned 107 primary care physicians with at least 100 patients aged 66 years and older (total 12 560) to a group receiving computerized decision-making support (CDS) or a control group. Physicians in the CDS group had access to information on current and past prescriptions through a dedicated computer link to the provincial seniors' drug-insurance program. When any of 159 clinically relevant prescribing problems were identified by the CDS software, the physician received an alert that identified the nature of the problem, possible consequences and alternative therapy. The rate of initiation and discontinuation of potentially inappropriate prescriptions was assessed over a 13-month period.
                In the 2 months before the study, 31.8% of the patients in the CDS group and 33.3% of those in the control group had at least 1 potentially inappropriate prescription. During the study the number of new potentially inappropriate prescriptions per 1000 visits was significantly lower (18%) in the CDS group than in the control group (relative rate [RR] 0.82, 95% confidence interval [CI] 0.69-0.98), but differences between the groups in the rate of discontinuation of potentially inappropriate prescriptions were significant only for therapeutic duplication by the study physician and another physician (RR 1.66, 95% CI 0.99-2.79) and drug interactions caused by prescriptions written by the study physician (RR 2.15, 95% CI 0.98-4.70).
                Computer-based access to complete drug profiles and alerts about potential prescribing problems reduces the rate of initiation of potentially inappropriate prescriptions but has a more selective effect on the discontinuation of such prescriptions.
We found a diversity of cap and co-payment policies. Poor reporting of the intensity of interventions and differences in setting, populations and interventions made it difficult to make comparisons across studies. Cap and co-payment polices can reduce drug use and save plan drug expenditures. However, although insufficient data on health outcomes were available, substantial reductions in the use of life-sustaining drugs or drugs that are important in treating chronic conditions may have adverse effects on health, and as a result increase the use of healthcare services and overall expenditures. Direct payments are less likely to cause harm if only non-essential drugs are included or exemptions are built in to ensure that patients receive needed medical care.