Association Between Copayment Amount and Filling of Medications for Angiotensin Receptor Neprilysin Inhibitors in Patients With Heart Failure

Background Angiotensin receptor neprilysin inhibitors (ARNI) reduce mortality and hospitalization for patients with heart failure. However, relatively high copayments for ARNI may contribute to suboptimal adherence, thus potentially limiting their benefits. Methods and Results We conducted a retrospective cohort study within a large, multi-site health system. We included patients with: ARNI prescription between November 20, 2020 and June 30, 2021; diagnosis of heart failure or left ventricular ejection fraction ≤40%; and available pharmacy or pharmacy benefit manager copayment data. The primary exposure was copayment, categorized as $0, $0.01 to $10, $10.01 to $100, and >$100. The primary outcome was prescription fill nonadherence, defined as the proportion of days covered <80% over 6 months. We assessed the association between copayment and nonadherence using multivariable logistic regression, and nonbinarized proportion of days covered using multivariable Poisson regression, adjusting for demographic, clinical, and neighborhood-level covariates. A total of 921 patients met inclusion criteria, with 192 (20.8%) having $0 copayment, 228 (24.8%) with $0.01 to $10 copayment, 206 (22.4%) with $10.01 to $100, and 295 (32.0%) with >$100. Patients with higher copayments had higher rates of nonadherence, ranging from 17.2% for $0 copayment to 34.2% for copayment >$100 (P<0.001). After multivariable adjustment, odds of nonadherence were significantly higher for copayment of $10.01 to $100 (odds ratio [OR], 1.93 [95% CI, 1.15-3.27], P=0.01) or >$100 (OR, 2.58 [95% CI, 1.63-4.18], P<0.001), as compared with $0 copayment. Similar associations were seen when assessing proportion of days covered as a proportion. Conclusions We found higher rates of not filling ARNI prescriptions among patients with higher copayments, which persisted after multivariable adjustment. Our findings support future studies to assess whether reducing copayments can increase adherence to ARNI and improve outcomes for heart failure.

Gender Differences and the Effect of Copayments on the Utilization of Health Care in Prison

This study examines differences in episodic health care utilization related to copayment fees in prison. Copayments in correctional institutions may affect men and women differently, as there are gender-specific health needs, differences in the frequencies men and women require medical services, and gendered differences in the financial resources at people's disposal inside the prison environment. Survey data and interviews from 140 males and females incarcerated across two prisons revealed copayments were a significant barrier for those seeking medical attention and reduced utilization. Results from content analysis and zero-inflated Poisson regression models demonstrated the copayments were a greater barrier to treatment for women compared to men, even when considering one's financial resources. Race and self-reported physical health were also significantly associated with avoiding care due to copayments.

Influence of Pharmaceutical Copayment on Emergency Hospital Admissions: A 1978-2018 Time Series Analysis in Spain

No studies have evaluated the influence of pharmaceutical copayment on hospital admission rates using time series analysis. Therefore, we aimed to analyze the relationship between hospital admission rates and the influence of the introduction of a pharmaceutical copayment system (PCS). In July 2012, a PCS was implemented in Spain, and we designed a time series analysis (1978–2018) to assess its impact on emergency hospital admissions. Hospital admission rates were estimated between 1978 and 2018 each month using the Hospital Morbidity Survey in Spain (the number of urgent hospital admissions per 100,000 inhabitants). This was conducted for men, women and both and for all-cause, cardiovascular and respiratory hospital discharges. Life expectancy was obtained from the National Institute of Statistics. The copayment variable took a value of 0 before its implementation (pre-PCS: January 1978–June 2012) and 1 after that (post-PCS: July 2012–December 2018). ARIMA (Autoregressive Integrated Moving Average) (2,0,0)(1,0,0) models were estimated with two predictors (life expectancy and copayment implementation). Pharmaceutical copayment did not influence hospital admission rates (with p-values between 0.448 and 0.925) and there was even a reduction in the rates for most of the analyses performed. In conclusion, the PCS did not influence hospital admission rates. More studies are needed to design health policies that strike a balance between the amount contributed by the taxpayer and hospital admission rates.

Low-Income Childless Adults' Access To Antidiabetic Drugs In Wisconsin Medicaid After Coverage Expansion

Medicaid coverage was expanded for childless adults in Wisconsin through an amended Section 1115 demonstration waiver on April 1, 2014. Coverage for prescription drugs was expanded via copayment reductions and a drug formulary expansion. We analyzed administrative drug claims data to evaluate changes in the use of and out-of-pocket spending on antidiabetic drugs among childless adults who experienced the drug coverage expansion. Compared to parents or caretakers, who were not affected by the expansion, childless adults experienced a significant increase of 4 percent in the use of antidiabetic drugs-driven mainly by an increase in the population using the drugs, rather than by more intense use. The expanded drug coverage also reduced the burden of out-of-pocket spending for childless adults by 70 percent. Our findings demonstrate that expanding prescription drug benefits led to increased access to antidiabetic drugs for childless adults in Wisconsin Medicaid.

The impact of generic aromatase inhibitors on initiation, adherence, and persistence among women with breast cancer: Applying multi-state models to understand the dynamics of adherence

PURPOSE

Clinical trials have clearly documented the survival benefit of aromatase inhibitors (AIs); however, many women fail to initiate (primary nonadherence) or remain adherent to AIs (secondary nonadherence). Prior studies have found that costs impact secondary nonadherence to medications but have failed to examine primary nonadherence. The purpose of this study is to examine primary and secondary adherence following the reduction in copays due to the introduction of generic AIs.

METHODS

Using Surveillance, Epidemiology, and End Results-Medicare data, we identified 50 054 women diagnosed with incident breast cancer between 2008 and 2013. We compare women whose copays would change and those whose would not, due to the receipt of cost-sharing subsidies before and after generics were introduced using a difference-in-difference (DinD) analysis. To examine primary and secondary nonadherence, we rely on a multistate model with four states (Not yet initiated, User, Not Using, and Death). We adjusted for baseline factors using inverse probability treatment weights and then simulated adherence for 36 months following diagnosis.

RESULTS

The generic introduction of AIs resulted in patients initiating AIs faster (DinD = -4.7%, 95%CI = -7.0, -2.3; patients not yet initiating treatment at 6-months), being more adherent (DinD ranging in absolute increase of 8.1%-10.4%) and being less likely to not be using the therapy (DinD range in absolute decrease of 1.2% at 6 months to 8.8% at 24 months) for women that do not receive a subsidy after generics were available.

CONCLUSIONS

Introduction of generic alternatives to AIs significantly reduced primary and secondary nonadherence.

Impact of Disparities in Reimbursement Rules Between Public and Private Sectors on Accessibility to Care in Moroccan Mandatory Health Insurance: A Cross-Sectional Study

BACKGROUND

Disparities in the reimbursement rules between the 2 funds that manage mandatory health insurance in Morocco could negatively affect the accessibility of insured persons to healthcare services and products.

OBJECTIVE

The objective is to analyze the impact of these disparities on access to care and to assess the insured's copayment difference between the 2 funds.

METHODS

Healthcare utilization rates of the insured population in the 2 funds were analyzed by sector, sex, and age groups for 2014. We also looked at the percentage of copayment paid by the insured depending on the fund, methods of reimbursement, type of care, and nature of diseases. The analysis was based on data retrieved and aggregated at the National Agency for Health Insurance.

RESULTS

The healthcare utilization rate differs significantly between the 2 funds. It is higher for the insured in the public sector (45%) compared with those in the private sector (18.5%) (P < .001). The healthcare utilization rate differs significantly according to the age groups in the 2 sectors (P < .001, respectively), and according to the sex of the insured in the 2 sectors (the healthcare utilization rate is higher for women than for men [P < .001, respectively]). The copayment percentage incurred by insured persons was 32.1% for employees in the public sector and 36.4% for employees in the private sector.

CONCLUSION

Differences in reimbursement rules between the 2 funds may be the cause of inequity in access to care between insured persons. This situation can jeopardize the objectives of a universal and equitable health insurance scheme.

Effect of the eQuality Health Bwindi Scheme on Utilization of Health Services at Bwindi Community Hospital in Uganda

Introduction: eQuality Health Bwindi (eQHB), a Community Based Health Insurance (CBHI) scheme was launched in March 2010 with the aim of generating income to maintain high quality care as well as increasing access to and utilization of health services at Bwindi Community Hospital (BCH). The main objective of this study was to explore evidence showing that eQHB scheme affected access and utilization of health services at BCH. The evidence generated would be used to inform decision making, policy and scale up of the scheme. Methods and Materials: This study applied qualitative and quantitative research methods. It involved a review of hospital records for the period July 2009-June 2014, a survey of 272 households, four focus group discussions, and six key informant interviews. Both quantitative and qualitative analysis techniques were applied for the analysis. Results: Outpatient attendance, inpatient admissions, and deliveries at the hospital increased by 65, 73, and 27%, respectively between FY 2009/10 and FY 2012/13. Utilization of health services by sick children from insured participants was greater than that of the uninsured members of the community (p-value = 0.0038). BCH services became more affordable. However, opting out of the scheme at a later stage in the review period was attributed to rising unaffordable premiums and co-payments. Failure to afford scheme membership, residing far from BCH and limited understanding of health insurance led to reduced BCH service utilization. Conclusions: eQHB has potential to increase access and utilization of health services at BCH. The challenges are; limited understanding of the concept of health insurance and unaffordable premiums and co-payments set to enable provision of high quality services. Recommendations: Based on these findings, intensified community sensitization on health insurance, establishment of satellite health facilities by BCH to bring services closer to members and transformation of eQHB to a savings/credit society in order to grow savings and subsequently reduce premiums are recommended. Government of Uganda should engage CBHIs countrywide to discuss achievement of UHC and establishment of a national health insurance scheme. A further study to guide setting of affordable premiums and copayments for eQHB is also recommended.

Pilot Study on the Cost of Some Oncohematology Diseases in Bulgaria

The goal of the current study is to perform a pilot study of the cost of some oncohematology diseases in Bulgaria. This is a pilot broader burden of disease research. The official report of the National health insurance fund provided information about the total expenditures paid for medicines, ambulatory services, and hospitalizations in 2015 and 2016. To evaluate the costs from a patient perspective, an internet inquiry was organized with the support of the patient organization. The inquiry contained questions regarding the patients' demography, type of oncohematology disease, year of diagnosis, quality of life (EuroQol v5D), and additional out of pocket expenditures. Quality of Life data were statistically analyzed and Kruskal-Wallis analysis of variance was performed. From 2015 to 2016 the number of patients with oncohematological diseases decreased by approximately 3000 people. Less than 30% were hospitalized and the hospitalization cost decreased, but the cost for medicines increased by nearly 1.5 million Euros. Cost for medicines almost tripled the hospitalization cost. The reported mean quality of life was 0.749 (SD 0.203). There was positive correlation between QoL and current disease state (p = 0.008) and age (p = 0.025). 42% reported to have additional expenditures related to their oncohematology disease, 22% reported other expenditures (diet, change of everyday habits etc.) and 42% reported to have productivity loses due to loss of employment or change of work, 44% of the respondents reported additional payment for medicines for concomitant diseases. Thus, the total cost (public funds and patients) accounted for 37,708,764 Euro. Despite the high public expenditures, the indirect costs due to productivity loses are higher. Costs for medicines are higher than costs of inpatient treatment, but this tendency is observed in all European countries. The increases in the costs of medicines are compensated by reduced costs of hospitalization. Despite their higher costs, newer medicines are an effective and reasonable investment from a societal perspective. Currently the higher levels of copayment increase the burden on the patients.

Do interventions that address patient cost-sharing improve adherence to prescription drugs? A systematic review of recently published studies

INTRODUCTION

Poor prescription drug adherence is common, jeopardizing the benefits of treatment and increasing the costs of health care in the United States. A frequently reported barrier to adherence is patient out-of-pocket (OOP) costs. Areas Covered: This systematic review examines interventions that address patient cost-sharing to improve adherence to prescription drugs and reduce costs of care. Twenty-eight published studies were identified with 22 distinct interventions. Most papers were published in or after 2010, and nearly a third were published after 2014. Expert Opinion: Many of the interventions were associated with improved adherence compared to controls, but effects were modest and varied across drug classes. In some studies, adherence remained stable in the intervention group, but declined in the control group. Patient OOP costs generally declined following the intervention, usually as a direct result of the financial structure of the intervention, such as elimination of copayments, and costs to health plans for prescription drugs increased accordingly. For those studies that reported drug and nondrug costs, lower health plan nondrug medical spending generally compensated for increased spending on prescription drugs. With increasing health-care spending, especially for prescription drugs, efforts to improve prescription drug adherence in the United States are important. Federal policies regarding prescription drug prices may have an impact on cost-related nonadherence, but the content and timing of any policies are hard to predict. As such, employers and health plans will face greater pressure to explore innovative approaches to lowering costs and increasing access for beneficiaries. Value-based financial incentive models have the potential to be a part of this effort; research should continue to evaluate their effectiveness.

Relationship between patient copayments in Medicare Part D and vaccination claim status for herpes zoster and tetanus-diphtheria-acellular pertussis

OBJECTIVE

To assess the relationship between copay amount and vaccination claim submission status for tetanus-diphtheria-acellular pertussis (Tdap) and herpes zoster (GSK study identifier: HO-14-14319).

METHODS

Retrospective analyses were performed using vaccination administrative claims data in patients aged ≥65 years with ≥1 claim for Tdap or zoster vaccines between 2012 and 2014. To avoid confounding by other financial responsibility, analyses were conducted among patients in the copayment phase of insurance. The impact of patient copay amount on vaccination claim status ("canceled" vs. "paid") was evaluated by logistic regression separately for Tdap and zoster, adjusting for patient and provider characteristics.

RESULTS

A total of 81,027 (39.2% with canceled claims) and 346,417 patients (56.8% with canceled claims) were included in the Tdap and zoster analyses, respectively. Mean (standard deviation) copay for canceled vs. paid claims was $37.2 (18.4) vs. $31.1 (20.1) for Tdap and $64.9 (36.9) vs. $53.5 (38.8) for zoster. The adjusted odds ratios (ORs) for a canceled Tdap vaccine claim, compared with $0 copay, were 1.19 ($1-25 copay), 1.76 ($26-50 copay), 2.42 ($51-75 copay) and 2.40 ($76-100 copay), all p < .001. The adjusted ORs for a canceled zoster vaccine claim, compared with $0 copay, were 1.02 ($1-25), 1.39 ($26-50), 1.66 ($51-75), 2.07 ($76-100) and 2.71 (>$100), all p < .001 except for $1-25 (p = .172).

CONCLUSIONS

High patient copay is a barrier to Tdap and zoster vaccinations in Medicare Part D patients. Providing vaccines at low or no copay may improve vaccination rates in these adults. GSK study identifier: HO-14-14319.

Willingness to Pay for Colorectal Cancer Screening and Effect of Copayment in Southern Thailand

Background:

The incidence rate of colorectal cancer in Thailand is increasing. Hence, the nationwide screening programme with copayment is being considered. There are two proposed screening alternatives: annual fecal immunochemical test (FIT) and once-in-10-year colonoscopy. A copayment for FIT is 60 Thai baht (THB) per test (≈ 1.7 USD); a copayment for colonoscopy is 2,300 THB per test (≈ 65.5 USD).

Methods:

The willingness to pay (WTP) technique, which is theoretically founded on a cost-benefit analysis, was used to assess an effect of copayment on the uptake. Subjects were patients aged 50-69 years without cancer or screening experience. WTP for the proposed tests was elicited.

Results:

Nearly two thirds of subjects were willing to pay for FIT. Less than half of subjects were willing to pay for colonoscopy. Among them, median WTP for both tests was greater than the proposed copayments. In a probit model, knowing CRC patient and presence of companion were associated with non-zero WTP for FIT. Presence of companion, female, and family history of cancer were associated with non-zero WTP for colonoscopy. After adjustment for starting price in the linear model, marital status, drinking behavior, and risk attitude were associated with WTP. None of factors was significant for colonoscopy. Uptake decreased as levels of copayment increased. At proposed copayments, the uptake rates of 59.8% and 21.6% were estimated for colonoscopy and FIT respectively. The demand for FIT was price inelastic; the demand for colonoscopy was price elastic. Estimates of optimal copayment were 62.1 THB for FIT and 460.2 THB for colonoscopy. At the optimal copayment, uptake rates would be 59.8% for FIT and 42.3% for colonoscopy.

Conclusion(s):

More subjects were willing to pay for FIT than for colonoscopy (59.0% versus 46.5%). The estimated uptake rates were 59.8% and 21.6% for colonoscopy and FIT at the proposed copayments.

Do Reduced Copayments Affect Mortality after Surgery due to Stroke? An Interrupted Time Series Analysis of a National Cohort Sampled in 2003-2012

BACKGROUND

The South Korean government introduced a policy in 2 phases, in September 2005 and in January 2010, for reducing copayments for patients with critical diseases, including stroke, to prevent excessive medical expenditures and to ease economic barriers. Previous studies of the effect of this policy were focused primarily on cancer. Therefore, we investigated the relationship between this policy and 1-year mortality after surgery among patients with stroke.

METHODS

We used data from the Korean National Health Insurance sampling cohort (n = 2173 in 2003-2012) and performed an interrupted time series analysis.

RESULTS

Approximately 26% of the patients died within 1 year after surgery. The time trends after reducing copayments from 10% to 5% (phase 2) were inversely associated with risk of 1-year mortality (relative risk = .855, 95% confidence interval: .749-.975; P = .0196). In addition, this inverse association was greater in patients with low incomes, of older ages, and with higher Charlson comorbidity indices.

CONCLUSIONS

The introduction of a policy for reducing copayments to ease excessive cost burdens for patients with stroke was positively associated with a reduced risk of 1-year mortality after surgical treatment due to stroke. On the basis of our results, health policy makers should make an effort to identify vulnerable populations and to overcome economic barriers for providing effective alternatives to ensure patients receive optimal health care.

The impact of change from copayment to coinsurance on medical care usage and expenditure in outpatient setting in older Koreans

Patient cost-sharing change was implemented on August 1, 2007, for outpatient care in the clinic setting in Korea from copayment to coinsurance. This study aims to estimate the effect of the policy change on medical care usage and expenditure in older Koreans. By using national health insurance claims data from the Health Insurance Reimbursement Assessment Service, this study analyzed the entire 137 million claims for a total of approximately 4.1 million patients aged 60 to 69 years who had been diagnosed and/or treated for outpatient care in clinics from January 1, 2007, to December 31, 2008. Medical care usage was defined as the proportion of all beneficiaries in each group who visited clinics and the mean number of visit days per beneficiary. Medical care expenditure per visit day was expressed as total costs, reimbursed amount, and patient's out-of-pocket payment. Data on January through June of 2008 were analyzed as compared with the same months of 2007. Raw difference-in-difference and multiple regression analyses were performed. The interaction coefficients, which measured the impact of cost-sharing change, was -0.078 in model 1 and -0.039 in model 2 (P < .0001). In conclusion, a cost-sharing change from copayment to coinsurance reduced medical care usage and expenditure.

Reducing patient copayment levels for topical and systemic treatments in plaque psoriasis as a case for evidence-based, sustainable pharmaceutical policy change in Greece

AIM

Psoriasis is a chronic inflammatory skin disease that requires treatment to manage co-morbidities and improve patient quality-of-life. This study estimated the budget impact to National Organization for Health Care Services Provision (EOPYY) of changing reimbursement of psoriasis treatment with topical and systemic, non-biologic, agents (75%) to bring it on par with that of biologic agents (100%) in Greece.

METHODS

The Business Intelligence database of EOPYY was used to identify and provide analytics on patients with plaque psoriasis. Permission for use of anonymized data was obtained by the administration of EOPYY. EOPYY is responsible for funding healthcare and pharmaceutical care services for ∼95% of the permanent population in the country. Pre-defined ICD-10 codes were applied to identify patients with plaque psoriasis and at least one reimbursed prescription between 1 June 2014 and 31 May 2015. Age, gender, medications, and cost were recorded for these patients.

RESULTS

Of the 45,581 unique patients identified through completely anonymized data on the e-prescription system, 72% were on treatment with topicals only and accounted for 5% of EOPYY psoriasis expenditure. Another 9% of patients were on methotrexate or a per os (POS, orally administered) systemic agent and accounted for 2.35% of total expenditure. Approximately 12% of total patients were on treatment with a biologic-containing regimen and accounted for almost 90% of psoriasis expenditure. Patients on biologics were younger than patients on topical and systemic treatments. The burden to EOPYY of adjusting reimbursement levels for topical and systemic, non-biologic, treatments to 100% of their cost was estimated at €2.05 per patient per month for topical treatments (monotherapy) and an additional €9.5 per patient per month for treatment with methotrexate, POS systemic agents, and their combinations with topical agents. This additional cost is expected to be offset by averting 200 earlier than clinically necessary switches from topical and systemic, non-biologic, treatments to expensive biologics a year.

CONCLUSION

In circumstances of severe funding constraints for social health insurance in Greece, bringing patient copayment levels for psoriasis treatment on par with each other may aid proper clinical management of the condition, whilst achieving adequate treatment outcomes at optimal cost.

Examining the Value of Subsidies of Health Plans and Cost-Sharing for Prescription Drugs in the Health Insurance Marketplace

BACKGROUND

The Affordable Care Act (ACA) initiated federally and state-run health insurance exchanges, or marketplaces, with health plans offering subsidies for plan members as well as coverage for essential health benefits, to help individuals, families, and small businesses find health plans that fit their specific needs. A recent study found that the value of these healthcare subsidies varied with the number of health plans in the different geographic rating areas, but that study only examined the premiums and the deductibles of those health plans.

OBJECTIVES

To examine the value of subsidies of health plans, including cost-sharing for prescription drugs in the health insurance marketplace.

METHODS

We have used publicly available health plan data from HealthCare.gov and from county population data obtained from the US Census Bureau in June 2015. The average-weighted premium; medical deductible; medical maximum out-of-pocket spending; and cost-sharing for generic drugs, preferred and nonpreferred brand-name drugs, and specialty drugs were calculated for the second lowest-cost silver plan in each geographic rating area. These were then compared across geographic areas with different numbers of plans to determine the value of the subsidies. We also compared the difference between the cost of the average silver plan and the second lowest-cost silver plan for each area to determine the cost to enrollees if they selected the average silver plan.

RESULTS

The monetary value of the subsidies provided by health plans was lower in areas with a larger number of plans, because the second lowest-cost silver plans in these areas tended to have lower premiums and higher deductibles. For the most common type of cost-sharing for generic and for preferred brand-name drugs, plan enrollees would likely have a lower or similar copayment if they selected the average-cost silver plan instead of the second lowest-cost silver plan. However, they may end up paying approximately $8 less in copayment for nonpreferred branded drugs and approximately 4% less for coinsurance after a deductible for specialty drugs if they resided in a geographic area with fewer than 11 plans.

CONCLUSION

The value of subsidies provided by the ACA-initiated health plans in the healthcare marketplace, including cost-sharing for prescription drugs, varies across geographic areas with different numbers of health plans. This suggests that potential enrollees should consider cost-sharing for prescription drugs in addition to health plans' premiums and deductibles when choosing their health plan.

Copayments and Emergency Department Use Among Adult Medicaid Enrollees

A number of state Medicaid programs have recently proposed or implemented new or increased copayments for nonemergent emergency department (ED) visits. Evidence suggests that copayments generally reduce the level of healthcare utilization, although there is little specific evidence regarding the effectiveness of copayments in reducing nonurgent ED use among Medicaid enrollees or other low-income populations. Encouraging efficient and appropriate use of healthcare services will be of particular importance for Medicaid programs as they expand under the Patient Protection and Affordable Care Act. This analysis uses national data from 2001 to 2009 to examine the effect of copayments on nonurgent ED utilization among nonelderly adult enrollees. We find that visits among Medicaid enrollees in state-years where a copayment is in place are significantly less likely to be for nonurgent reasons. Our findings suggest that copayments may be an effective tool for reducing use of the ED for nonurgent care.

Subsidy and parental attitudes toward pediatric health care in the Tokyo metropolitan area

BACKGROUND

In Japan, the number of municipalities that offer free medical care for children has increased. This policy, however, might unintentionally aggravate the overcrowded situation of pediatric ambulatory services in Japan. We investigated the relationship between parents' health-care seeking attitudes according to child symptom severity and the amount of copayment, as well as parents' socioeconomic and demographic factors.

METHODS

We used data for 4385 people from the Japanese Study of Stratification, Health, Income and Neighborhood (J-SHINE), which consisted of stratified random sampling of those aged from 25 to 50 years who lived in Tokyo and neighboring areas. Outcome variables were respondent health-care seeking attitudes toward their children's mild and severe symptoms of cold. Logistic regression models were developed for each dependent variable.

RESULTS

A total of 1606 respondents with one or more children under the age of 15 years were included in the analysis. For mild symptoms of cold, no subsidy (OR: 0.51, 95%CI: 0.38-0.69) and partial subsidy (OR, 0.71; 95%CI: 0.54-0.95) were associated with fewer "visit on that day" answers, compared with full subsidy. Income and respondent educational level were not associated with the outcome. For severe symptoms of cold, the OR of no subsidy (0.61; 95%CI: 0.30-1.23) and that of partial subsidy (0.91; 95%CI: 0.40-2.07) were not statistically significant.

CONCLUSION

Imposing a small copayment might prevent visits to medical facilities for mild symptoms of cold, but will not prevent visits for severe symptoms of cold.

The effects of introducing an electronic prescription system with no copayments

BACKGROUND

To examine the impact of introducing an electronic prescription system with no copayments on the number of prescriptions, the size of prescriptions, and the number of visits and phone calls to primary physicians.

METHODS

Fixed regression models using monthly data on per capita prescriptions claims and consultations between 2009 and 2013 at the municipality level, before and after the introduction of the electronic prescription system.

RESULTS

The electronic prescription system with no copayment increased the number of prescriptions by between 6.0 and 8.1 %. It decreased the average size of each prescription, but it did not decrease the number of consultations.

CONCLUSION

The reduced direct and indirect costs of obtaining prescriptions after the introduction of the electronic prescription system changed the financial incentives facing the patients and physicians. This led to significant changes in the level and size of prescriptions and illustrates the importance of financial incentives.

No payments, copayments and faux payments: are medical practitioners adequately equipped to manage Medicare claiming and compliance?

The complexity of Medicare claiming means it is often beyond the comprehension of many, including medical practitioners who are required to interpret and apply Medicare every day. A single Medicare service can be the subject of 30 different payment rates, multiple claiming methods and a myriad of rules, with severe penalties for non-compliance, yet the administrative infrastructure and specialised human resourcing of Medicare may have decreased over time. As a result, medical practitioners experience difficulties accessing reliable information and support concerning their claiming and compliance obligations. Some commentators overlook the complexity of Medicare and suggest that deliberate misuse of the system by medical practitioners is a significant contributor to rising healthcare costs, although there is currently no empirical evidence to support this view. Quantifying the precise amount of leakage caused by inappropriate claiming has proven an impossible task, although current estimates are $1-3 billion annually. The current government's proposed copayment plan may cause increases in non-compliance and incorrect Medicare claiming, and a causal link has been demonstrated between medical practitioner access to Medicare education and significant costs savings. Medicare claiming is a component of almost every medical interaction in Australia, yet most education in this area currently occurs on an ad hoc basis. Research examining medical practitioner experiences and understanding regarding Medicare claiming and compliance is urgently required to adapt medicine responsibly to our rapidly changing healthcare environment.

Payments, promotion, and the purple pill

Understanding competition in the US drug market requires knowing how sensitive demand is to prices. The relevant prices for insured consumers are copayments. There are many studies of copayment elasticity in the health literature, but they are of limited applicability for studies of competition. Because of a paucity of data, such studies typically control for neither competitor copayment nor advertising. Whereas previous studies examined copayment sensitivity when copayments for branded drugs move in unison, this study examines copayment sensitivity when copayments diverge. This study uses unique panel data of insurance copayments and utilization for 77 insurance groups, as well as data on advertising. The results indicate that demand can be much more sensitive to copayment than previously recognized. Manufacturers selling drugs with higher copayments than branded competitors can lose substantial market share. Manufacturers can offset the loss of demand by increasing advertising to physicians, but it is costly.

Can increases in CHIP copayments reduce program expenditures on prescription drugs?

OBJECTIVE

The primary aim is to explore whether prescription drug expenditures by enrollees changed in Alabama's CHIP program, ALL Kids, after copayment increases in fiscal year 2004. The subsidiary aim is to explore whether non-pharmaceutical expenditures also changed.

DATA SOURCES

Data on ALL Kids enrollees between 1999-2007, obtained from claims files and the state's administrative database.

STUDY DESIGN

We used data on children who were enrolled between one and three years both before and after the changes to the copayment schedule, and estimate regression models with individual-level fixed effects to control for time-invariant heterogeneity at the child level. This allows an accurate estimate of how program expenditures change for the same individual following copayment changes. Primary outcomes of interest are expenditures for prescription drugs by class and brand-name and generic versions. We estimate models for the likelihood of any use of prescription drugs and expenditure level conditional on use.

PRINCIPAL FINDINGS

Following the copayment increase, the probability of any expenditure decline by 5.8%, brand name drugs by 6.9%, generic drugs by 7.4%. Conditional on any use, program expenditures decline by 7.9% for all drugs, by 9.6% for brand name drugs, and 6.2% for generic drugs. The largest declines are for antihistamine drugs; the least declines are for Central Nervous System agents. Declines are smaller and statistically weaker for children with chronic health conditions. Concurrent declines are also seen for non-pharmaceutical medical expenditures.

CONCLUSIONS

Copayment increases appear to reduce program expenditures on prescription drugs per enrollee and may be a useful tool for controlling program costs.

Did copayment changes reduce health service utilization among CHIP enrollees? Evidence from Alabama

OBJECTIVE

To explore whether health care utilization changed among enrollees in Alabama's CHIP program, ALL Kids, following copayment increases at the beginning of fiscal year 2004.

DATA SOURCES

Data on all ALL Kids enrollees over 1999-2009 are obtained from claims files and the state's administrative database.

STUDY DESIGN

We use pooled month-level data for all enrollees and conduct covariate-adjusted segmented regression models. Health services considered are inpatient care, emergency department (ED) visits, brand-name prescription drugs, generic prescription drugs, physician office visits and outpatient-services, ambulance services, allergy treatments, and non-preventive dental services. Physician well-visits, preventive dental services, and service use by Native-Americans--which saw no copayment increases--serve as counterfactuals.

PRINCIPAL FINDINGS

There are significant declines in utilization for inpatient care, physician visits, brand-name medications, and ED visits following the copayment increases. By and large, utilization did not decline, or declined only temporarily, for those services and for those enrollees that who not subject to increased copayments.

CONCLUSIONS

Copayment increases reduced utilization of many health services among ALL Kids enrollees. Concerns remain regarding the long-term health consequences to low-income children of copayment-induced reductions in health care utilization.

Willingness to participate in a lifestyle intervention program of patients with type 2 diabetes mellitus: a conjoint analysis

BACKGROUND

Several studies suggest that lifestyle interventions can be effective for people with, or at risk for, diabetes. The participation in lifestyle interventions is generally low. Financial incentives may encourage participation in lifestyle intervention programs.

OBJECTIVE

The main aim of this exploratory analysis is to study empirically potential effects of financial incentives on diabetes patients' willingness to participate in lifestyle interventions. One financial incentive is negative ("copayment") and the other incentive is positive ("bonus"). The key part of this research is to contrast both incentives. The second aim is to investigate the factors that influence participation in a lifestyle intervention program.

METHODS

Conjoint analysis techniques were used to empirically identify factors that influence willingness to participate in a lifestyle intervention. For this purpose diabetic patients received a questionnaire with descriptions of various forms of hypothetical lifestyle interventions. They were asked if they would be willing to participate in these hypothetical programs.

RESULTS

In total, 174 observations were rated by 46 respondents. Analysis showed that money was an important factor independently associated with respondents' willingness to participate. Receiving a bonus seemed to be associated with a higher willingness to participate, but having to pay was negatively associated with participation in the lifestyle intervention.

CONCLUSION

Conjoint analysis results suggest that financial considerations may influence willingness to participate in lifestyle intervention programs. Financial disincentives in the form of copayments might discourage participation. Although the positive impact of bonuses is smaller than the negative impact of copayments, bonuses could still be used to encourage willingness to participate.

Modeling the potential impact of a prescription drug copayment increase on the adult asthmatic medicaid population

OBJECTIVES

The Commonwealth of Massachusetts increased the copayment for prescription drugs by $1.50 for Medicaid (MassHealth) beneficiaries in 2003. We sought to determine the likely health outcomes and cost shifts attributable to this copayment increase using the example of inhaled corticosteroids (ICS) use among adult asthmatic Medicaid beneficiaries.

METHOD

We compared the predicted costs and health outcomes projected over a 1-year time horizon with and without the increase in copayment from the perspective of MassHealth, providers, pharmacies, and MassHealth beneficiaries by employing decision analysis simulation model.

RESULTS

In a target population of 17,500 adult asthmatics, increased copayments from 50 cent to $2.00 would result in an additional 646 acute events per year, caused by increased drug nonadherence. Annual combined net savings for the state and federal governments would be $2.10 million. Projected MassHealth savings are attributable to both decreased drug utilization and lower pharmacy reimbursement rates; these more than offset the additional costs of more frequent acute exacerbations. Pharmacies would lose $1.98 million in net revenues, MassHealth beneficiaries would pay an additional $0.28 million, and providers would receive additional $0.16 million.

CONCLUSION

Over its first year of implementation, increase in the prescription drug copayment is expected to produce more frequent acute exacerbations among asthmatic MassHealth beneficiaries who use ICS and to shift the financial burden from government to other stakeholders.

Suboptimal statin adherence and discontinuation in primary and secondary prevention populations

OBJECTIVES

To compare statin nonadherence and discontinuation rates of primary and secondary prevention populations and to identify factors that may affect those suboptimal medication-taking behaviors.

DESIGN

Retrospective cohort utilizing pharmacy claims and administrative databases.

SETTING

A midwestern U.S. university-affiliated hospital and managed care organization (MCO).

PATIENTS

Non-Medicaid MCO enrollees, 18 years old and older, who filled 2 or more statin prescriptions from January 1998 to November 2001; 2258 secondary and 2544 primary prevention patients were identified.

MEASUREMENTS

Nonadherence was assessed by the percent of days without medication (gap) over days of active statin use, a measurement known as cumulative multiple refill-interval gap (CMG). Discontinuation was identified by cessation of statin refills prior to the end of available pharmacy claims data.

RESULTS

On average, the primary and secondary groups went without medication 20.4% and 21.5% of the time, respectively (P=.149). Primary prevention patients were more likely to discontinue statin therapy relative to the secondary prevention cohort (relative risk [RR], 1.24; 95% confidence interval [CI], 1.08 to 1.43). Several factors influenced nonadherence and discontinuation. Fifty percent of patients whose average monthly statin copayment was < US dollars 10 discontinued by the end of follow-up (3.9 years), whereas 50% of those who paid >US dollars 10 but <or=US dollars 20 and >US dollars 20 discontinued by 2.2 and 1.0 years, respectively (RR, 1.39 and 4.30 relative to <US dollars 10 copay, respectively).

CONCLUSIONS

Statin nonadherence and discontinuation was suboptimal and similar across prevention categories. Incremental efforts, including those that decrease out-of-pocket pharmaceutical expenditures, should focus on improving adherence in high-risk populations most likely to benefit from statin use.