OBJECTIVE: To examine the independent and combined contributions of insurance status and supply of health professionals on coverage of antihypertensive treatment among adults in Mexico. DESIGN: Population based study. SETTING: Mexico. PARTICIPANTS: 4032 hypertensive adults (2967 uninsured and 1065 insured): 1065 uninsured adults matched with 1065 adults insured through Seguro Popular, a programme to expand health insurance coverage to uninsured people in Mexico. MAIN OUTCOME MEASURES: Coverage of antihypertensive treatment and coverage of antihypertensive treatment with control of blood pressure. RESULTS: Rates of treatment for hypertension varied by insurance status and supply of health professionals. Hypertensive adults insured through Seguro Popular had a significantly higher probability of receiving antihypertensive treatment (odds ratio 1.50, 95% confidence interval 1.27 to 1.78) and receiving antihypertensive treatment with control of blood pressure (1.35, 1.00 to 1.82). Greater supply of health professionals in areas with coverage through Seguro Popular was a significant predictor of antihypertensive treatment after adjusting for covariates (1.49, 1.00 to 2.20). CONCLUSIONS: Expansion of healthcare coverage to uninsured people in Mexico was associated with greater use of antihypertensive treatment and blood pressure control, particularly in areas with a greater supply of health professionals.
PURPOSE: The effects of a medication assistance program with medication therapy management (MTM) on the clinical outcomes and health-related quality of life (HQOL) of renal transplant recipients were studied.
METHODS: All renal transplant recipients who were enrolled in the Medication Access Program at the Medical College of Georgia for at least one year were included in the study. Patients' demographics, number of graft rejections (for one year pre-enrollment and one year post-enrollment), and diagnoses of hypertension, diabetes, and dyslipidemia were recorded and confirmed by medical and pharmacy records. The use of antihypertensive, antidiabetic, antilipemic, and immunosuppressant agents and laboratory values for fasting blood glucose, glycosylated hemoglobin (HbA(1c)), blood pressure, low-density-lipoprotein (LDL) cholesterol, total cholesterol, triglycerides, and serum immunosuppressant concentrations were identified for one year pre-enrollment and one year post-enrollment. HQOL was measured at the time of enrollment and one year post-enrollment.
RESULTS: Thirty-six adult renal transplant recipients were included in the study. All patients had hypertension, 72% had dyslipidemia, and 42% had diabetes. Patients received significantly more antihypertensive agents post-enrollment versus pre-enrollment (p < 0.001) and significantly more antidiabetic agents (p = 0.004) and antilipemics (p = 0.001). Measures of fasting blood glucose, glycosylated hemoglobin, LDL cholesterol, total cholesterol, triglycerides, blood pressure, and number of graft rejections decreased from pre-enrollment levels (p < 0.01). A significantly greater number of patients reached target serum cyclosporine levels post-enrollment versus pre-enrollment (p = 0.008). HQOL was significantly increased one year post-enrollment (p < 0.01).
CONCLUSION: A medication assistance program that included MTM services improved medication access, clinical outcomes, and HQOL in renal transplant recipients.
BACKGROUND: Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries. METHODS: We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at 1,000 dollars and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements. RESULTS: After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more. CONCLUSIONS: A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.
OBJECTIVE:To evaluate medication adherence, medication safety, health care utilization, and health outcomes among patients enrolled in a subsidized prescription program.
DESIGN:Cross-sectional study.
SETTING:Conducted as part of the Prescription Access program, a subsidized prescription program serving indigent patients residing in Franklin County, Ohio.
PATIENTS:Patients qualifying for enrollment in the program were uninsured and had a household income of 200% or less of federal poverty level. Approximately 5% of the 2,500 patients (mean age, 70.6 years) enrolled in the program were systematically selected from a computer-generated patient enrollment report.
INTERVENTION:Telephone interviews conducted by a pharmacist or advanced student pharmacist between January and September 2002.
MAIN OUTCOME MEASURES:Patterns of medication use and safety, level of health care utilization, and health outcomes.
RESULTS:A total of 104 patients reported taking a mean (+/- SD) of 6.7 +/- 3.8 medications. A total of 72 (69%) patients reported taking their medications correctly, and 90 (87%) reported finishing their medication course as prescribed. Medication refills were obtained by 75 (72%) patients, but of these patients, only 55 (73%) indicated that they obtained their refills on time. Adverse effects occurred in 25 (24%) patients, and 2 patients reported an allergic reaction. A total of 51 (49%) patients made unscheduled visits to their primary care physician, another health care facility, an emergency department, and/or were admitted to a hospital. Unscheduled visits occurred more often among nonadherent patients (59%) than adherent patients (44%), but not significantly so. In addition, 82 (79%) patients reported an improvement in health-related quality of life (QOL); 90 (87%) had a means of transportation to obtain medications; and 93 (89%) indicated that they would have to skip medications or give up necessities, if they were not enrolled in a subsidized prescription program.
CONCLUSION:An improvement in self-reported QOL and a high rate of medication adherence demonstrate support for the benefits of this and similar subsidized prescription drug programs. A high rate of additional health care utilization, especially among nonadherent patients, indicates an area for further analysis, program revisions, and/or patient education.
BACKGROUND: Chronically ill patients often experience difficulty paying for their medications and, as a result, use less than prescribed.
OBJECTIVES: The objectives of this study were to determine the relationship between patients with diabetes' health insurance coverage and cost-related medication underuse, the association between cost-related underuse and health outcomes, and the role of comorbidity in this process.
RESEARCH DESIGN: We used a patient survey with linkage to insurance information and hemoglobin A1C (A1C) test results.
PATIENTS: We studied 766 adults with diabetes recruited from 3 Veterans Affairs (VA), 1 county, and 1 university healthcare system.
MAIN OUTCOMES: Main outcomes consisted of self-reported medication underuse as a result of cost, A1C levels, symptom burden, and Medical Outcomes Study 12-Item Short-Form physical and mental functioning scores.
RESULTS: Fewer VA patients reported cost-related medication underuse (9%) than patients with private insurance (18%), Medicare (25%), Medicaid (31%), or no health insurance (40%; P <0.0001). Underuse was substantially more common among patients with multiple comorbid chronic illnesses, except those who used VA care. The risk of cost-related underuse for patients with 3+ comorbidities was 2.8 times as high among privately insured patients as VA patients (95% confidence interval, 1.2-6.5), and 4.3 to 8.3 times as high among patients with Medicare, Medicaid, or no insurance. Individuals reporting cost-related medication underuse had A1C levels that were substantially higher than other patients (P <0.0001), more symptoms, and poorer physical and mental functioning (all P <0.05).
CONCLUSIONS: Many patients with diabetes use less of their medication than prescribed because of the cost, and those reporting cost-related adherence problems have poorer health. Cost-related adherence problems are especially common among patients with diabetes with comorbid diseases, although the VA's drug coverage may protect patients from this increased risk.
OBJECTIVE: To examine the impact of 2 cost-containment efforts in prescription benefits in successive years that included changes in copayment and coverage levels, expanded generic coverage, and brand name prescription drug limit-of-coverage in a Medicare health maintenance organization (HMO). The benefit changes included moving to a drug benefit with increased total coverage and higher copayments in the first year (1998) and to one with brand name limit-of-coverage and unlimited generic availability in the second year (1999). STUDY DESIGN: A repeated-measures analytical design with enrollee follow-up before and after introduction of the 2 policies. PATIENTS AND METHODS: A cohort of 2411 older adults continuously enrolled in a Medicare HMO since 1998 was followed up for 1 year pre-post for healthcare service utilization and costs; 259 patients enrolled since 1997 were available to test the effects of the first policy change. RESULTS: Bivariate and multivariate analyses found a significant decrease of 27% in prescription costs, a 4% decrease in physician visits, and a 6% decrease in total costs associated with the change in prescription benefit in the second year (1999). The policy change in the first year (1998) resulted in a 29% increase in prescription costs and 38% increased total costs for the HMO. CONCLUSIONS: Introduction of a prescription benefit that included substantial brand name limit-of-coverage and generic drug coverage expansion was associated with significantly reduced prescription costs. In addition, this change did not seem to increase nonprescription-related healthcare service use in the population.
BACKGROUND: We examined the effects of a three-prescription monthly payment limit (cap) on the use of psychotropic drugs and acute mental health care by noninstitutionalized patients with schizophrenia. We hypothesized that reducing access to such drugs would increase the use of emergency mental health services and the rate of partial hospitalizations (full-day or half-day treatment programs) and psychiatric-hospital admissions. METHODS: We linked Medicaid claims data for a period of 42 months with clinical records from two community mental health centers (CMHCs) and the single state psychiatric hospital in New Hampshire, where Medicaid imposed a three-prescription limit on reimbursement for drugs during 11 months (months 15 through 25) of the study. For comparison, we used Medicaid claims for a period of 42 months in New Jersey, which had no limit on drug reimbursement. The study patients (n = 268) and the comparison patients (n = 1959) were permanently disabled, noninstitutionalized patients with schizophrenia, 19 through 60 years of age, who were insured by Medicaid. We conducted interrupted time-series regression analyses to estimate the effects of the cap on the use of medications and mental health services. RESULTS: The cap resulted in immediate reductions (range, 15 to 49 percent) in the use of antipsychotic drugs, antidepressants and lithium, and anxiolytic and hypnotic drugs (P < 0.01). It also resulted in coincident increases of one to two visits per patient per month in visits to CMHCs (range of increase, 43 to 57 percent; P < 0.001) and sharp increases in the use of emergency mental health services and partial hospitalization (1.2 to 1.4 episodes per patient per month), but no change in the frequency of hospital admissions. After the cap was discontinued, the use of medications and most mental health services reverted to base-line levels (measured in the first 14 months of the study). The estimated average increase in mental health care costs per patient during the cap ($1,530) exceeded the savings in drug costs to Medicaid by a factor of 17. CONCLUSIONS: Limits on coverage for the costs of prescription drugs can increase the use of acute mental health services among low-income patients with chronic mental illnesses and increase costs to the government, even aside from the increases caused in pain and suffering on the part of patients.
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs.
To examine the independent and combined contributions of insurance status and supply of health professionals on coverage of antihypertensive treatment among adults in Mexico.
DESIGN:
Population based study.
SETTING:
Mexico.
PARTICIPANTS:
4032 hypertensive adults (2967 uninsured and 1065 insured): 1065 uninsured adults matched with 1065 adults insured through Seguro Popular, a programme to expand health insurance coverage to uninsured people in Mexico.
MAIN OUTCOME MEASURES:
Coverage of antihypertensive treatment and coverage of antihypertensive treatment with control of blood pressure.
RESULTS:
Rates of treatment for hypertension varied by insurance status and supply of health professionals. Hypertensive adults insured through Seguro Popular had a significantly higher probability of receiving antihypertensive treatment (odds ratio 1.50, 95% confidence interval 1.27 to 1.78) and receiving antihypertensive treatment with control of blood pressure (1.35, 1.00 to 1.82). Greater supply of health professionals in areas with coverage through Seguro Popular was a significant predictor of antihypertensive treatment after adjusting for covariates (1.49, 1.00 to 2.20).
CONCLUSIONS:
Expansion of healthcare coverage to uninsured people in Mexico was associated with greater use of antihypertensive treatment and blood pressure control, particularly in areas with a greater supply of health professionals.
