Medicare part D's implementation improved access to and affordability of prescription drugs for the elderly without prior drug insurance. Effects for specific drugs and drug classes are less well understood. We assessed part D's impact on antipsychotic medication (APM) utilization and out-of-pocket costs among elderly without prior drug insurance. Retail pharmacy claims from 3 nationwide pharmacy chains were used to analyze 2 time-series designs: (1) a policy model, to obtain a policymaker's perspective: what was the overall impact of part D on APM use and costs among elderly without drug insurance in 2005 with the opportunity to enroll? And (2) a clinical model, to obtain a clinician's perspective: what would happen to elderly without drug insurance in 2005 who did enroll in part D--would they be able to get APMs? At what cost? Subgroup analyses among part D enrollees evaluated potentially different effects for patients who received a subsidy and patients who used antidementia drugs. In the policy model, part D implementation was associated with a 5% increase in APM use and a 37% reduction in out-of-pocket costs, suggesting a modest need for APMs among all previously uninsured elderly. Patients who did enroll in part D (clinical model) had a 97% increase in APM use and a 62% decrease in out-of-pocket costs, suggesting that patients who needed APMs were able to access them at low cost through the part D program. Part D implementation was associated with increased use and affordability of APMs for the elderly without prior drug insurance.
OBJECTIVE: To determine whether a 24% increase in patient co-payments in January 2005 and two related co-payment changes for medicines subsidised under the Australian Pharmaceutical Benefits Scheme (PBS) were associated with changes in dispensings in Western Australia (WA).
METHOD: We analysed aggregate monthly prescription counts and defined daily dose per 1,000 population per day (DDD/1,000/day) for atypical antipsychotics, combination asthma medicines, HmgCoA reductase inhibitors (statins) and proton-pump inhibitors (PPIs). Trends pre and post the co-payment increase in January 2005 were compared.
RESULTS: In three of the four categories examined, prescription counts were significantly lower following the increase in co-payment thresholds. Compared with dispensings prior to the co-payment increase, prescriptions fell by 8% for combination asthma medicines (p<0.001), 9% for PPIs (p<0.001) and 5% for statins (p<0.001). Following the rise in co-payments, DDD/1,000/day decreased for all four categories. Decreases in dispensings to concessional beneficiaries were between 4% and 5% larger than for general beneficiary patients.
CONCLUSIONS AND IMPLICATIONS: The reduction in the both prescription counts and DDD/1,000/day observed for combination asthma medicines, PPIs and statins, which all remained above co-payment thresholds, suggests the increase in PBS co-payments has affected utilisation of these subsidised medicines. The results indicate that increases in patient contributions particularly impact on concessional patients' ability to afford prescription medicines.
BACKGROUND: Health plans that increase prescription cost-sharing for their patients may increase overall plan costs. We analyzed the impact on health plan spending of a switch in public drug insurance from full coverage to a prescription copayment (copay), and then to income-based deductibles plus coinsurance (IBD).
METHODS: We studied British Columbia residents 65 years of age or older who were dispensed inhaled steroids, beta2 agonists or anticholinergics on or after January 1996. Multivariable linear regression was used to estimate health plan costs for the population using inhalers by the Ministry of Health (MOH) during the copay and IBD policies. We estimated costs for excess physician visits and emergency hospitalizations based on data from a previously published cohort study and cost data from the MOH. We estimated the net change in MOH spending as the sum of changes in spending for inhalers, physician visits, hospitalizations, and policy administration costs.
RESULTS: Net health plan spending increased by C$1.98 million per year during the copay policy [95% confidence interval (CI): 0.10-4.34], and C$5.76 million per year during the first 10 months of the IBD policy (95% CI: 1.75-10.58). Out-of-pocket spending by older patients increased 30% during the copay policy (95% CI: 24-36) and 59% during the IBD policy (95% CI: 56-63).
CONCLUSIONS: British Columbia's experience indicates that cost containment focused on cost-shifting to patients may increase net expenditures for the treatment of some diseases. Health plans should consult experts to anticipate the potential cross-program impacts of policy changes.
This study evaluates the effect of Medicare Part D among seniors who previously lacked drug coverage, using time-trend analyses of patient-level dispensing data from three pharmacy chains. Of 114,766 seniors without drug benefits, 55 percent initiated drug insurance under Part D. After the penalty-free Part D enrollment period, use of statins, clopidogrel, and proton pump inhibitors stabilized at levels ranging from 11 percent to 37 percent above the trend that would have been expected if Part D had not been implemented. Patients reaching the Part D coverage gap (12 percent) experienced a decrease in essential medication use ranging from 5.7 percentage points per month for warfarin to 6.3 percentage points for statins.
BACKGROUND: Information about the effect of the Medicare Part D Prescription Drug Benefit on drug utilization and expenditures is limited.
OBJECTIVE: To estimate changes in prescription utilization and out-of-pocket expenditures attributable to Part D among a sample of persons eligible for the benefit.
DESIGN: Generalized estimating equations were used to estimate changes in expenditures and utilization among beneficiaries. A control group was included to control for secular trends unrelated to the Part D benefit.
SETTING: National pharmacy chain representing approximately 15% of all U.S. retail pharmacy sales.
PARTICIPANTS: Persons age 66 to 79 years (those eligible for Part D) and a control group of persons age 60 to 63 years (those ineligible for Part D). The final sample represented approximately 5.1 million unique beneficiaries and 1.8 million unique control individuals.
MEASUREMENTS: Prescription utilization (measured in pill-days) and out-of-pocket expenditures, as determined from pharmacy claims from September 2004 to April 2007.
RESULTS: During the penalty-free Part D enrollment period (January 2006 to May 2006), average monthly drug utilization increased by 1.1% (95% CI, 0.5% to 1.7%; P < 0.001) and out-of-pocket expenditures decreased by 8.8% (CI, 6.6% to 11.0%; P < 0.001). After enrollment stabilized (June 2006 to April 2007), average monthly drug utilization increased by 5.9% (CI, 5.1% to 6.7%; P < 0.001) and out-of-pocket expenditures decreased by 13.1% (CI, 9.6% to 16.6%; P = 0.003). Compared with eligible nonenrollees, enrollees had higher out-of-pocket expenditures and utilization at baseline but experienced significantly larger decreases in expenditures and increases in utilization after enrollment.
LIMITATIONS: Analyses were limited to claims within 1 pharmacy chain. The effect of the "doughnut hole" and the effect of changes on clinical outcomes were not evaluated.
CONCLUSION: The Medicare Part D prescription benefit resulted in modest increases in average drug utilization and decreases in average out-of-pocket expenditures among Part D beneficiaries. Further research is needed to examine patterns among other beneficiaries and to evaluate the effect of these changes on health outcomes.
BACKGROUND: Rapid growth in prescription drug costs has compelled insurers to require increased patient cost-sharing.
OBJECTIVE: The aim of this study was to compare the effects of 2 recent cost-sharing policies on emergency hospitalizations due to chronic obstructive pulmonary disease, asthma, or emphysema (CAE), and on physician visits.
METHODS: We analyzed data from a large-scale natural experiment in British Columbia (BC), Canada. The cost-sharing policies were a fixed copayment policy (fixed copay policy) and an income-based deductible (IBD) policy with 25% coinsurance (IBD policy). Prescription, physician billing, and hospitalization records were obtained from the BC Ministry of Health. From the total population of BC residents > or = 65 years of age, we extracted data from all patients dispensed an inhaled corticosteroid, beta(2)-agonist, or anticholinergic from June 30, 1997, to April 30, 2004. Poisson regression was used to evaluate the impact of the policies in a cohort of patients receiving long-term inhaler treatment. An identically defined historical control group unaffected by the policy changes was used for comparison.
RESULTS: The study population included 37,320 users of long-term inhaled medications from the BC population of 576,000 persons > or = 65 years of age. During the IBD period but not the fixed copay period, emergency hospitalizations for CAE increased 41% (95% CI for adjusted rate ratio [RR], 1.24-1.60) in patients > or = 65 years of age. There was also a significant increase in physician visits of 3% (95% CI for adjusted RR, 1.01-1.05). No significant increases were observed during the fixed copay period. In a secondary analysis using a concurrent control group, we estimated a smaller but significant increase in emergency CAE hospitalizations of 29% (95% CI for adjusted RR, 1.09-1.52). This analysis also showed increases in physician visits (fixed copay period RR, 1.03 [95% CI for adjusted RR, 1.01-1.05]; IBD period RR, 1.07 [95% CI for adjusted RR, 1.05-1.08]).
CONCLUSION: The results suggest that the IBD policy was likely associated with an increased risk for emergency hospitalization and physician visits in these users of inhaled medications who were aged > or = 65 years.
OBJECTIVE: Antidepressant therapies are underused among older adults and could be further curtailed by patient cost-sharing requirements. The authors studied the effects of two sequential cost-sharing policies in a large, stable population of all British Columbia seniors: change from full prescription coverage to 10-25 dollars copayments (copay) in January 2002 and replacement with income-based deductibles and 25% coinsurance in May 2003.
METHODS: PharmaNet data were used to calculate monthly dispensing of antidepressants (in imipramine-equivalent milligrams) among all British Columbia residents age 65 and older beginning January 1997 through December 2005. Monthly rates of starting and stopping antidepressants were calculated. Population-level patterns over time were plotted, and the effects of implementing cost-sharing policies on antidepressant use, initiation, and stopping were examined in segmented linear regression models.
RESULTS: Implementation of the copay policy was not associated with significant changes in level of antidepressant dispensing or the rate of dispensing growth. Subsequent implementation of the income-based deductible policy also did not lead to a significant change in dispensing level but led to a significant (p=.02) decrease in the rate of growth of antidepressant dispensing. The copay policy was associated with a significant (p=.01) drop in the frequency of antidepressant initiation among persons with depression. Income-based deductibles reduced the rate of increase in antidepressant initiation over time. Implementation of the copay and income-based deductible policies did not have significant effects on stopping rates.
CONCLUSIONS: Introducing new forms of medication cost sharing appears to have the potential to reduce some use and initiation of antidepressant therapy by seniors. The clinical consequences of such reduced use need to be clarified.
PURPOSE: Patient co-payments for medicines subsidised under the Australian Pharmaceutical Benefits Scheme (PBS) increased by 24% in January 2005. We investigated whether this increase and two related co-payment changes were associated with changes in dispensings of selected subsidised medicines in Australia.
METHOD: We analysed national aggregate monthly prescription dispensings for 17 medicine categories, selected to represent a range of treatments (e.g. for diabetes, cardiovascular diseases, gout). Trends in medication dispensings from January 2000 to December 2004 were compared with those from January 2005 to September 2007 using segmented regression analysis.
RESULTS: Following the January 2005 increase in PBS co-payments, significant decrease in dispensing volumes were observed in 12 of the 17 medicine categories (range: 3.2-10.9%), namely anti-epileptics, anti-Parkinson's treatments, combination asthma medicines, eye-drops, glaucoma treatments, HmgCoA reductase inhibitors, insulin, muscle relaxants, non-aspirin antiplatelets, osteoporosis treatments, proton-pump inhibitors (PPIs) and thyroxine. The largest decrease was observed for medicines used in treating asymptomatic conditions or those with over-the-counter (OTC) substitutes. Decrease in dispensings to social security beneficiaries was consistently greater than for general beneficiaries following the co-payment changes (range: 1.8-9.4% greater, p = 0.028).
CONCLUSIONS: The study findings suggest that recent increase in Australian PBS co-payments have had a significant effect on dispensings of prescription medicines. The results suggest large increase in co-payments impact on patients' ability to afford essential medicines. Of major concern is that, despite special subsidies for social security beneficiaries in the Australian system, the recent co-payment increase has particularly impacted on utilisation for this group.
OBJECTIVES: To evaluate medication use, out-of-pocket spending, and medication switching during the transition period for patients dually eligible for Medicaid and Medicare (dual eligibles).
DESIGN: Time-trend analysis, using segmented linear regression.
SETTING: Patient-level pharmacy dispensing data from January 2005 to December 2006 from a large pharmacy chain with stores in 34 states.
PARTICIPANTS: Dual eligibles aged 65 and older.
MEASUREMENTS: Changes in utilization, patient copayments, and medication switching were analyzed using interrupted time trend analyses. Utilization and spending were evaluated for five study drugs: clopidogrel, proton pump inhibitors (PPIs), warfarin, and statins (essential drugs covered by Part D plans) and benzodiazepines (not covered through Part D but potentially covered through Medicaid).
RESULTS: Drug use for 13,032 dual eligibles was evaluated. There was no significant effect of the transition to Medicare Part D on use of all study drugs, including the uncovered benzodiazepines. Cumulative reductions were seen in copayments for all covered drugs after implementation of Part D, ranging from 25% annually for PPIs to 53% for warfarin, but there was a larger increase in copayments, 91% annually, for benzodiazepines after the transition. The rate of switching medications was 3.0 times as great for the PPIs after implementation of Part D than before implementation, but there was no significant change in the other study drug classes.
CONCLUSION: These findings in a single, large pharmacy chain indicate that the transition plan for dual eligibles led to less medication discontinuation and switching than many had expected. The substantially greater cost sharing for benzodiazepines highlights the importance of implementing a thoughtful transition plan when executing such a national policy.
BACKGROUND: Copayments (copays) for prescription drugs are a common policy among state Medicaid programs. Research exploring the effects of copays on pharmacy and health care utilization in Medicaid patients is limited, especially among patients with chronic disease.
OBJECTIVES: The goal of this research was to quantify the impact of a copay policy for prescription drugs on medication and health services utilization overall and among subjects with several common chronic diseases enrolled in a state Medicaid program.
RESEARCH DESIGN: Using aggregated pharmacy claims, segmented linear regression models were used to evaluate changes in overall and disease-specific pharmacy utilization after implementation of a copay policy. Trends in emergency department encounters, office visits, and hospitalizations were used to evaluate the impact of this policy on unintended consequences. Utilization among cohorts of patients with several chronic conditions were analyzed to determine if a differential response existed by drug indication.
RESULTS: After copay implementation, utilization of prescription drugs declined significantly by 17.2% (P < 0.0001). This pattern was observed at varying degrees for all drug classes investigated. Rates of emergency department encounters, office visits, or hospitalizations did not increase after the policy was introduced. Subjects with diabetes, respiratory disease, and schizophrenia immediately reduced their use of nonindicated drugs significantly more than drugs indicated for their condition.
CONCLUSIONS: Among Medicaid recipients, nominal copays are associated with significant reductions in use of clinically important drug classes. However, patients with chronic disease exhibited a differential response depending on the disease indication of the drug class.
Medicare part D's implementation improved access to and affordability of prescription drugs for the elderly without prior drug insurance. Effects for specific drugs and drug classes are less well understood. We assessed part D's impact on antipsychotic medication (APM) utilization and out-of-pocket costs among elderly without prior drug insurance. Retail pharmacy claims from 3 nationwide pharmacy chains were used to analyze 2 time-series designs: (1) a policy model, to obtain a policymaker's perspective: what was the overall impact of part D on APM use and costs among elderly without drug insurance in 2005 with the opportunity to enroll? And (2) a clinical model, to obtain a clinician's perspective: what would happen to elderly without drug insurance in 2005 who did enroll in part D--would they be able to get APMs? At what cost? Subgroup analyses among part D enrollees evaluated potentially different effects for patients who received a subsidy and patients who used antidementia drugs. In the policy model, part D implementation was associated with a 5% increase in APM use and a 37% reduction in out-of-pocket costs, suggesting a modest need for APMs among all previously uninsured elderly. Patients who did enroll in part D (clinical model) had a 97% increase in APM use and a 62% decrease in out-of-pocket costs, suggesting that patients who needed APMs were able to access them at low cost through the part D program. Part D implementation was associated with increased use and affordability of APMs for the elderly without prior drug insurance.
