Differences in Diabetic Prescription Drug Utilization and Costs Among Patients With Diabetes Enrolled in Colorado Marketplace and Medicaid Plans, 2014-2015

Importance

Increasing prices of antidiabetic medications in the US have raised substantial concerns about the effects of drug affordability on diabetes care. There has been little rigorous evidence comparing the experiences of patients with diabetes across different types of insurance coverage.

Objective

To compare the utilization patterns and costs of prescription drugs to treat diabetes among low-income adults with Medicaid vs those with Marketplace insurance in Colorado during 2014 and 2015.

Design, Setting, and Participants

This cross-sectional study included diabetic patients enrolled in Colorado Medicaid and Marketplace plans who were aged 19 to 64 years and had incomes between 75% and 200% of the federal poverty level during 2014 and 2015. Data analysis was conducted from September 2020 to April 2021.

Exposures

Health insurance through Colorado Medicaid or Colorado's state-based Marketplace.

Main Outcomes and Measures

Primary outcomes were drug utilization (prescription drug fills) and drug costs (total costs and out-of-pocket costs). The secondary outcome was months with an active prescription for noninsulin antidiabetic medications. An all payer claims database was combined with income data, and linear models were used to adjust for clinical and demographic confounders.

Results

Of 22 788 diabetic patients included in the study, 20 245 were enrolled in Medicaid and 2543 in a Marketplace plan. Marketplace-eligible individuals were older (mean [SD] age, 52.12 [10.60] vs 47.70 [11.33] years), and Medicaid-eligible individuals were more likely to be female (12 429 [61.4%] vs 1413 [55.6%]). Medicaid-eligible patients were significantly more likely than Marketplace-eligible patients to fill prescriptions for dipeptidyl peptidase 4 inhibitors (adjusted difference, -3.7%; 95% CI, -5.3 to -2.1; P < .001) and sulfonylureas (adjusted difference, -6.6%; 95% CI, -8.9 to -4.3; P < .001). Overall rates of insulin use were similar in the 2 groups (adjusted difference, -2.3%; -5.1 to 0.5; P = .11). Out-of-pocket costs for noninsulin medications were 84.4% to 95.2% lower and total costs were 9.4% to 54.2% lower in Medicaid than in Marketplace plans. Out-of-pocket costs for insulin were 76.7% to 94.7% lower in Medicaid than in Marketplace plans, whereas differences in total insulin costs were mixed. The percentage of months of apparent active medication coverage was similar between the 2 groups for 4 of 5 drug classes examined, with Marketplace-eligible patients having a greater percentage of months than Medicaid-eligible patients for sulfonylureas (adjusted difference, 5.3%; 95% CI, 0.3%-10.4%; P = .04).

Conclusions and Relevance

In this cross-sectional study, drug utilization across multiple drug classes was higher and drug costs were significantly lower for adults with diabetes enrolled in Medicaid than for those with subsidized Marketplace plans. Patients with Marketplace coverage had a similar percentage of months with an active prescription as patients with Medicaid coverage.

Current treatment patterns and medical costs for multiple myeloma in Japan: a cross-sectional analysis of a health insurance claims database

Aims: Various drugs have recently been launched for the treatment of multiple myeloma (MM). This increase in the number of treatment options has potentially changed treatment patterns and medical costs for patients with MM. Japanese public health insurance claims were analyzed to examine the change in the treatment patterns of MM drugs and medical costs per patient.Materials and methods: A claims database provided by Medical Data Vision was used, which includes data from ∼20 million patients from >300 acute care hospitals across Japan. The type of MM drugs prescribed and medical costs for patients with MM between April 2008 and December 2016 were examined using monthly cross-sectional analyses. Patients with an International Classification of Diseases, 10th Revision (ICD-10) diagnosis code of C90.0 were classified as having MM. MM drugs were defined by generic names.Results: In total, 19,137 patients with MM (average age at first diagnosis: 69.6 years; percentage of women: 47.9%) were identified from the database. The percentage of patients prescribed each MM drug changed substantially as novel drugs were launched. Total medical costs increased until 2010, then stabilized. MM drug costs increased from approximately 2010, but costs for other care decreased, particularly for hospitalization (including surgery).Limitations: The database contained data from large, acute care hospitals, which may have caused bias in terms of patients' clinical history and disease severity.Conclusions: Total medical costs for MM have remained stable since 2010. MM drug costs increased, but costs for other care decreased after the launch of lenalidomide in 2010 and other drugs in 2015 and later. More detailed research is required to confirm whether the launch of novel drugs caused the changes in medical costs.

The cost-effectiveness of isavuconazole compared to the standard of care in the treatment of patients with invasive fungal infection prior to differential pathogen diagnosis in the United Kingdom

Aims: To estimate the cost-effectiveness of isavuconazole compared with the standard of care, voriconazole, for the treatment of patients with invasive fungal infection disease when differential diagnosis of the causative pathogen has not yet been achieved at treatment initiation.Materials and methods: The economic model was developed from the perspective of the UK National Health Service (NHS) and used a decision-tree approach to reflect real-world treatment of patients with invasive fungal infection (IFI) prior to differential pathogen diagnosis. It was assumed that 7.8% of patients with IFI prior to differential pathogen diagnosis at treatment initiation actually had mucormycosis, and confirmation of pathogen identification was achieved for 50% of all patients during treatment. To extrapolate to a lifetime horizon, the model considered expected survival based on the patients' underlying condition. The model estimated the incremental costs (costs of drugs, laboratory analysis, hospitalization, and management of adverse events) and clinical outcomes (life-years (LYs) and quality-adjusted life-years (QALYs)) of first-line treatment with isavuconazole compared with voriconazole. The robustness of the results was assessed by conducting deterministic and probabilistic sensitivity analyses.Results: Isavuconazole delivered 0.48 more LYs and 0.39 more QALYs per patient at an incremental cost of £3,228, compared with voriconazole in the treatment of patients with IFI prior to differential pathogen diagnosis. This equates to an incremental cost-effectiveness ratio (ICER) of £8,242 per additional QALY gained and £6,759 per LY gained. These results were driven by a lack of efficacy of voriconazole in mucormycosis. Results were most sensitive to the mortality of IA patients and treatment durations.Conclusions: At a willingness to pay (WTP) threshold of £30,000 per additional QALY, the use of isavuconazole for the treatment of patients with IFI prior to differential pathogen diagnosis in the UK can be considered a cost-effective allocation of healthcare resources compared with voriconazole.

Specialty Drug Pricing and Out-of-Pocket Spending on Orally Administered Anticancer Drugs in Medicare Part D, 2010 to 2019

This study describes point-of-sale prices for orally administered anticancer drugs offered through Medicare Part D and out-of-pocket changes in spending as a result of decreasing coinsurance and price changes between 2010 and 2019.

Potential impact of pharmaceutical industry rebates on medication adherence

Many patients struggle to take their prescription medications as prescribed. Multiple interacting factors influence medication nonadherence. The cost of medications, particularly a patient's out-of-pocket cost, spans several of these domains. One proposed option for reducing a patient's out-of-pocket cost involves directly sharing manufacturer rebates with patients to lower their out-of-pocket costs at the pharmacy counter. Rebates are widely used across industries (eg, pharmaceutical manufacturers, tourism taxes, automobile manufacturers) in negotiations between sellers and buyers for a particular product. Medication rebates play an important role in the current US pharmaceutical marketplace. However, rebate contract terms are not publicly reported, so it is difficult for patients to determine if, and how, a rebate is reflected in their out-of-pocket costs. This commentary addresses the role of rebates in the current US healthcare landscape and their relationship with medication adherence.

Strategies Used by Adults Aged 65 and Over to Reduce Their Prescription Drug Costs, 2016-2017

In 2017, 86% of U.S. adults aged 65 and over reported being prescribed medication in the past 12 months (1). Most adults aged 65 and over have prescription drug coverage through either Medicare Part D or some source such as private health insurance, Medicaid, or Veterans Administration coverage (2). However, previous data indicate that some may still use strategies to reduce prescription drug costs, including not taking their medication as prescribed or asking their doctor for a lower-cost medication (3). This report examines the percentage of adults aged 65 and over who used these strategies to reduce their prescription drug costs in the past 12 months by selected characteristics.

[Pharmaceutical expenditures in the different municipalities of Rome (Italy): impact of socioeconomic conditions of the resident population]

Pharmaceutical expenditure is a cost item that is monitored continuously, to verify the appropriateness of prescriptions, the good use of available resources and to contain costs. However, socioeconomic differences in the population affect health conditions and consequently health expenditure. A comparison of socio-economic determinants and per-capita pharmaceutical expenditure in the different municipalities of Roma Capitale (Capital city of Rome, Italy) indicates that higher expenditures occur in areas characterized by lower socio-economic conditions.

How does retirement affect healthcare expenditures? Evidence from a change in the retirement age

Using individual-level administrative panel data from Hungary, we estimate causal effects of retirement on outpatient and inpatient care expenditures and pharmaceutical expenditures. Our identification strategy is based on an increase in the official early retirement age of women, using that the majority of women retire upon reaching that age. According to our descriptive results, people who are working before the early retirement age have substantially lower healthcare expenditures than nonworkers, but the expenditure gap declines after retirement. Our causal estimates from a two-part (hurdle) model show that the shares of women with positive outpatient care, inpatient care, and pharmaceutical expenditures, respectively, decrease by 3.0, 1.4, and 1.3 percentage points in the short run due to retirement. These results are driven by the relatively healthy, by those who spent some time on sick leave and by the less educated. The effect of retirement on the size of positive healthcare expenditures is generally not significant.

The Multi-Billion Dollar Drug-Sensitive Spending Opportunity

Chronic diseases increase utilization and avoidable drug-sensitive spending, but little is done to optimize medication use and drive value. Value-based approaches to health care financing should shift focus to drug-sensitive spending to balance patient access and quality improvement with cost containment.

Availability of Pharmacist-Prescribed Contraception in California, 2017

This survey study estimates the extent to which pharmacies in California are making pharmacist-prescribed contraception available since it was permitted, but not required, in April 2016.

Retrospective, multicohort analysis of the Clinical Practice Research Datalink (CPRD) to determine differences in the cost of medication wastage, dispensing fees and prescriber time of issuing either short (<60 days) or long (≥60 days) prescription lengths in primary care for common, chronic conditions in the UK

OBJECTIVES

To investigate patterns of early repeat prescriptions and treatment switching over an 11-year period to estimate differences in the cost of medication wastage, dispensing fees and prescriber time for short (<60 days) and long (≥60 days) prescription lengths from the perspective of the National Health Service in the UK.

SETTING

Retrospective, multiple cohort study of primary care prescriptions from the Clinical Practice Research Datalink.

PARTICIPANTS

Five random samples of 50 000 patients each prescribed oral drugs for (1) glucose control in type 2 diabetes mellitus (T2DM); (2) hypertension in T2DM; (3) statins (lipid management) in T2DM; (4) secondary prevention of myocardial infarction; and (5) depression.

PRIMARY AND SECONDARY OUTCOME MEASURES

The volume of medication wastage from early repeat prescriptions and three other types of treatment switches was quantified and costed. Dispensing fees and prescriber time were also determined. Total unnecessary costs (TUC; cost of medication wastage, dispensing fees and prescriber time) associated with <60 day and ≥60 day prescriptions, standardised to a 120-day period, were then compared.

RESULTS

Longer prescription lengths were associated with more medication waste per prescription. However, when including dispensing fees and prescriber time, longer prescription lengths resulted in lower TUC. This finding was consistent across all five cohorts. Savings ranged from £8.38 to £12.06 per prescription per 120 days if a single long prescription was issued instead of multiple short prescriptions. Prescriber time costs accounted for the largest component of TUC.

CONCLUSIONS

Shorter prescription lengths could potentially reduce medication wastage, but they may also increase dispensing fees and/or the time burden of issuing prescriptions.

Real-life cost of vitamin K antagonist treatment in patients with non-valvular atrial fibrillation in France in 2013

AIMS

Data highlighting the cost drivers for non-valvular atrial fibrillation (NVAF) patients in terms of vitamin K antagonist (VKA) treatment and monitoring are lacking in France. This study aimed to evaluate the real-life daily cost of VKA treatment in 2013, in French patients suffering from NVAF.

METHODS

This longitudinal observational study was performed using the EGB (Echantillon Généraliste des Bénéficiaires) database, a random sample of the French national insurance (NHI) database, which covers 80% of the population. All adult patients whose first NVAF anticoagulant treatment in 2013 was a VKA were analyzed. Costs were calculated for the duration of follow-up and then divided by the number of days of therapy. The analysis was performed both from the French NHI perspective (amount reimbursed by the NHI) and from a collective perspective.

RESULTS

In this study, 3,254 NVAF patients treated with VKA in 2013 were included, and this sample comprised 52.6% males. The mean daily cost of VKA treatment was €1.13 (±1.18) according to the collective perspective (89.4% of this cost was associated to INR measurement) and €1.05 (±1.16) according to the NHI perspective.

LIMITATIONS

As diagnoses associated with procedures are not available in the EGB database, proxies were used, and an algorithm was created to define the AF population.

CONCLUSIONS

This analysis is the first to consider an exhaustive spectrum of the costs of VKA treatment in France using EGB data. VKA medication requires exhaustive follow-up, and, thus, associated costs are important. The results of the present study confirmed this close follow-up for VKA patients, making the cost of treatment by VKA nearly 10-times more expensive than the cost of medication itself.

Insulin prices, availability and affordability: a cross-sectional survey of pharmacies in Hubei Province, China

BACKGROUND

Poor access to affordable insulin results in serious and needless complications and premature deaths for those with diabetes who need this essential medicine. To help address this issue, we assessed insulin availability, prices, affordability and price components in Hubei Province as China has the heaviest burden of diabetes globally.

METHODS

In 2016, insulin availability and price data was collected in the capital and five other cities. A total of 30 public sector outlets (hospitals and primary care institutions) and 30 private pharmacies were sampled, using an adaptation of the World Health Organization/Health Action International methodology, Data was collected for all human and analogue insulins in stock, then analyzed by type (prandial, basal or pre-mixed) and duration of action. Prices were expressed as Median Price Ratios (MPRs) to Australian PBS prices. Price components were tracked for five insulin products in two cities.. Affordability was assessed as the number of days' wages of the lowest paid unskilled government worker needed to purchase 10 ml 100 IU/ml (approximately 30 days' supply).

RESULTS

Mean availability was highest in public hospitals for prandial (70%), basal (80%) and pre-mixed insulin (90%). In primary care institutions and private pharmacies mean availability ranged from 10% to 33%. Median prices of all insulin types were higher that Australian PBS prices in all three sectors for human and analogue insulins (ranging from1.36-2.59 times). Patients have to pay 4 to 16 days' wages to purchase a month's treatment depending on the insulin type and sector. The largest component of the patient price was the manufacturers' selling price (60%). Taxes in the form of import duties and VAT are applied in some sectors.

CONCLUSIONS

The availability of insulin in primary care institutions and private retail pharmacies was very low in Hubei. Only public hospitals had good insulin availability. Insulin prices were high in all sectors making this life-saving medicine unaffordable, especially for those on low incomes. Governments should consider using its bargaining power to reduce prices, abolish taxes on essential medicines such as insulin, and develop strategies for more equitable access to insulin.

Rising Prices of Targeted Oral Anticancer Medications and Associated Financial Burden on Medicare Beneficiaries

Purpose The high cost of oncology drugs threatens the affordability of cancer care. Previous research identified drivers of price growth of targeted oral anticancer medications (TOAMs) in private insurance plans and projected the impact of closing the coverage gap in Medicare Part D in 2020. This study examined trends in TOAM prices and patient out-of-pocket (OOP) payments in Medicare Part D and estimated the actual effects on patient OOP payments of partial filling of the coverage gap by 2012. Methods Using SEER linked to Medicare Part D, 2007 to 2012, we identified patients who take TOAMs via National Drug Codes in Part D claims. We calculated total drug costs (prices) and OOP payments per patient per month and compared their rates of inflation with general health care prices. Results The study cohort included 42,111 patients who received TOAMs between 2007 and 2012. Although the general prescription drug consumer price index grew at 3% per year over 2007 to 2012, mean TOAM prices increased by nearly 12% per year, reaching $7,719 per patient per month in 2012. Prices increased over time for newly and previously launched TOAMs. Mean patient OOP payments dropped by 4% per year over the study period, with a 40% drop among patients with a high financial burden in 2011, when the coverage gap began to close. Conclusion Rising TOAM prices threaten the financial relief patients have begun to experience under closure of the coverage gap in Medicare Part D. Policymakers should explore methods of harnessing the surge of novel TOAMs to increase price competition for Medicare beneficiaries.

The price may not be right: the value of comparison shopping for prescription drugs

OBJECTIVES

To measure variations in drug prices across and within zip codes that may reveal simple strategies to improve patients' access to prescribed medications.

STUDY DESIGN

We compared drug prices at different types of pharmacies across and within local markets. In-store prices were compared with a Web-based service providing discount coupons for prescription medications. Prices were collected for 2 generic antibiotics because most patients have limited experience with them and are less likely to know the price ranges for them.

METHODS

Drug prices were obtained via telephone from 528 pharmacies in Los Angeles (LA) County, California, from July to August 2014. Online prices were collected from GoodRx, a popular Web-based service that aggregates available discounts and directly negotiates with retail outlets.

RESULTS

Drug prices found at independent pharmacies and by using discount coupons available online were lower on average than at grocery, big-box, or chain drug stores for 2 widely prescribed antibiotics. The lowest-price prescription was offered at a grocery, big-box, or chain drug store in 6% of zip codes within the LA County area. Drug prices varied dramatically within a zip code, however, and were less expensive in lower-income areas. The average price difference within a zip code was $52 for levofloxacin and $17 for azithromycin.

CONCLUSIONS

Price shopping for medications within a small geographic area can yield considerable cost savings for the uninsured and consumers in high-deductible health plans with high negotiated prices. Clinicians and patient advocates have an incentive to convey this information to patients to improve adherence to prescribed medicines and lower the financial burden of purchasing prescription drugs.

Use of generic and essential medicines for prevention and treatment of cardiovascular diseases in Portugal

BACKGROUND

The successful control of cardiovascular diseases at the lowest possible cost requires the use of the most effective and affordable medicines. We aimed to describe the trends in the ambulatory use of medicines for prevention and treatment of cardiovascular diseases [Anatomic Therapeutic Chemical classification system (ATC): C and B01A] in Portugal, between 2004 and 2012, and to estimate the potential for expenditure reduction through changes in patterns of use.

METHODS

We analysed sell-out data, expressed as defined daily doses (DDD) and pharmacy retail price (€), from a nationwide database. We estimated potential reduction in expenditures through the increase, up to 90% of the volume of DDD, in the use of generic and essential medicines; the latter were defined according to guidelines from Portugal and another European country.

RESULTS

Overall consumption increased by approximately 50% from 2004 to 2012, reaching nearly 2400 million DDD, whereas expenditure decreased to 753 million € (-31.3% since 2006). Use of generics and essential medicines increased, representing 43.6 and 39.9% of DDD consumption in 2012, respectively. The 40 most used groups of medicines in 2012 accounted for just over 80% of overall consumption; among these, increase in use of generics and essential medicines would have contributed to a saving of 275 million €.

CONCLUSIONS

Changes in patterns of consumption of medicines towards a more frequent use of generics, a preferential use of essential medicines and a more rational use of fixed-dose combinations may contribute to a more efficient use of health resources.

Identifying patients with cost-related medication non-adherence: a big-data approach

BACKGROUND

Millions of Americans encounter access barriers to medication due to cost; however, to date, there is no effective screening tool that identifies patients at risk of cost-related medication non-adherence (CRN).

OBJECTIVE

By utilizing a big-data approach to combining the survey data and electronic health records (EHRs), this study aimed to develop a method of identifying patients at risk of CRN.

METHODS

CRN data were collected by surveying patients about CRN behaviors in the past 3 months. By matching the dates of patients' receipt of monthly Social Security (SS) payments and the dates of prescription orders for 559 Medicare beneficiaries who were primary SS claimants at high risk of hospitalization in an urban academic medical center, this study identified patients who ordered their outpatient prescription within 2 days of receipt of monthly SS payments in 2014. The predictive power of this information on CRN was assessed using multivariate logistic regression analysis.

RESULTS

Among the 559 Medicare patients at high risk of hospitalization, 137 (25%) reported CRN. Among those with CRN, 96 (70%) had ordered prescriptions on receipt of SS payments one or more times in 2014. The area under the Receiver Operating Curve was 0.70 using the predictive model in multivariate logistic regression analysis.

CONCLUSION

With a new approach to combining the survey data and EHR data, patients' behavior in delaying filling of prescription until funds from SS checks become available can be measured, providing some predictive value for cost-related medication non-adherence. The big-data approach is a valuable tool to identify patients at risk of CRN and can be further expanded to the general population and sub-populations, providing a meaningful risk-stratification for CRN and facilitating physician-patient communication to reduce CRN.

Out-of-pocket spending on drugs and pharmaceutical products and cost-related prescription non-adherence among Canadians with chronic disease

BACKGROUND

Approximately one-third of Canadians' prescription medication costs are paid directly out-of-pocket. This study attempts to determine if out-of-pocket spending greater than 5% of household income on drugs and pharmaceutical products is associated with cost-related prescription non-adherence among people with cardiovascular-related chronic conditions.

DATA AND METHODS

The data are from the survey on Barriers to Care for People with Chronic Health Conditions. Three categories of out-of-pocket spending on drugs and pharmaceutical products as a percentage of household income were identified: 0%, more than 0% to less than 5%, and 5% or more. Log-binomial regression was used to investigate associations between category of out-of-pocket spending and cost-related non-adherence.

RESULTS

In 2012, about 80% of people aged 40 or older who lived in British Columbia, Alberta, Saskatchewan or Manitoba and had cardiovascular-related chronic conditions reported out-of-pocket spending on drugs and pharmaceutical products; 4.8% reported out-of-pocket spending of at least 5% of their household income. These individuals were significantly older, more often lived in households with incomes less than $30,000, and more often reported multiple morbidities than did people whose out-of-pocket spending on drugs and pharmaceutical products was less than 5% of household income. When the results were adjusted for age and sex, people whose spending amounted to 5% or more of household income were almost three times as likely (prevalence rate ratio = 2.6) to report cost-related prescription non-adherence than were those spending less than 5%.

INTERPRETATION

Spending at least 5% of household income on drugs and pharmaceutical products was significantly associated with cost-related prescription non-adherence. Additional data are required to determine if even lower levels of spending put individuals at risk of cost related non-adherence.

Healthcare costs associated with cardiovascular events in patients with hyperlipidemia or prior cardiovascular events: estimates from Swedish population-based register data

OBJECTIVES

To estimate healthcare costs of new cardiovascular (CV) events (myocardial infarction, unstable angina, revascularization, ischemic stroke, transient ischemic attack, heart failure) in patients with hyperlipidemia or prior CV events.

METHODS

A retrospective population-based cohort study was conducted using Swedish national registers and electronic medical records. Patients with hyperlipidemia or prior CV events were stratified into three cohorts based on CV risk level: history of major cardiovascular disease (CVD), coronary heart disease (CHD) risk-equivalent, and low/unknown risk. Propensity score matching was applied to compare patients with new events to patients without new events for estimation of incremental costs of any event and by event type.

RESULTS

A CV event resulted in increased costs over 3 years of follow-up, with the majority of costs occurring in the 1st year following the event. The mean incremental cost of patients with a history of major CVD (n = 6881) was €8588 during the 1st year following the event. This was similar to that of CHD risk-equivalent patients (n = 3226; €6663) and patients at low/unknown risk (n = 2497; €8346). Ischemic stroke resulted in the highest 1st-year cost for patients with a history of major CVD and CHD risk-equivalent patients (€10,194 and €9823, respectively); transient ischemic attack in the lowest (€3917 and €4140). Incremental costs remained elevated in all cohorts during all three follow-up years, with costs being highest in the major CVD history cohort.

CONCLUSIONS

Healthcare costs of CV events are substantial and vary considerably by event type. Incremental costs remain elevated for several years after an event.

Sofosbuvir initial therapy abandonment and manufacturer coupons in a commercially insured population

OBJECTIVES

To describe rates of sofosbuvir initial medication adherence as a function of the insurer-required member cost (ie, out-of-pocket cost) and to determine how manufacturer coupons affect insurer-required member cost.

STUDY DESIGN

Observational cross-sectional analysis.

METHODS

Administrative pharmacy claims data from 13 million commercially insured members were used to identify sofosbuvir new starts between January 2014 and September 2014. Members were categorized as either sofosbuvir initial adherence or as abandoning therapy. A multivariate logistic regression model adjusting for sociodemographic characteristics, severity of illness, and total drug costs (health insurer plus member amount) for non-sofosbuvir pharmacy claims in 2014 was used to evaluate the association between insurer-required member cost and initial medication adherence. In a sub-analysis, sofosbuvir index claims with coupon data available were analyzed to determine how coupon use impacted insurer-required member cost.

RESULTS

A total of 67.3% of members had a pre-coupon member cost of < $250 for their index sofosbuvir claim. Just 201 (5.0%) members were exposed to a member cost of more than $10,000. The logistic regression model demonstrated an association between member cost and abandonment starting at $2500 to < $5000 (odds ratio: 1.9; 95% CI, 1.01-3.43; P = .0393). The average member sofosbuvir index claim cost was $1349 before coupon was applied, and $28 after. Overall, coupons offset the member amounts paid by 98%: $771,593 of the $787,860 member cost requested by the insurer.

CONCLUSIONS

These findings indicate that a 30-day supply sofosbuvir member cost of > $2500 was associated with increased initial therapy abandonment, and that manufacturer coupons substantially reduced sofosbuvir insurer-required member cost. Insurers and policy makers should consider the impact of member cost on medication adherence and the impact coupons have on the actual member cost.

The Budget Impact of Biosimilar Infliximab (Remsima®) for the Treatment of Autoimmune Diseases in Five European Countries

INTRODUCTION

Inflammatory autoimmune diseases (rheumatoid arthritis, ankylosing spondylitis, Crohn's disease, ulcerative colitis, psoriasis, and psoriatic arthritis) have a considerable impact on patients' quality of life and healthcare budgets. Biosimilar infliximab (Remsima(®)) has been authorized by the European Medicines Agency for the management of inflammatory autoimmune diseases based on a data package demonstrating efficacy, safety, and quality comparable to the reference infliximab product (Remicade(®)). This analysis aims to estimate the 1-year budget impact of the introduction of Remsima in five European countries.

METHODS

A budget impact model for the introduction of Remsima in Germany, the UK, Italy, the Netherlands, and Belgium was developed over a 1-year time horizon. Infliximab-naïve and switch patient groups were considered. Only direct drug costs were included. The model used the drug-acquisition cost of Remicade. The list price of Remsima was not known at the time of the analysis, and was assumed to be 10-30% less than that of Remicade. Key variables were tested in the sensitivity analysis.

RESULTS

The annual cost savings resulting from the introduction of Remsima were projected to range from €2.89 million (Belgium, 10% discount) to €33.80 million (Germany, 30% discount). If any such savings made were used to treat additional patients with Remsima, 250 (Belgium, 10% discount) to 2602 (Germany, 30% discount) additional patients could be treated. The cumulative cost savings across the five included countries and the six licensed disease areas were projected to range from €25.79 million (10% discount) to €77.37 million (30% discount). Sensitivity analyses showed the number of patients treated with infliximab to be directly correlated with projected cost savings, with disease prevalence and patient weight having a smaller impact, and incidence the least impact.

CONCLUSION

The introduction of Remsima could lead to considerable drug cost-related savings across the six licensed disease areas in the five European countries.

FUNDING

Mundipharma International Ltd.

The drivers of overspending on prescription drugs in Quebec

According to data from the most recent edition of the Canadian Rx Atlas, Quebec was the province with the highest total spending per capita on prescription drugs. The difference between Quebec and the rest of Canada was 35%, which translates into $1.5 billion dollars of extra spending. This analysis explores the economic cost drivers of the higher level of pharmaceutical spending in Quebec. While much of the additional spending was driven by a higher volume of drugs being prescribed overall, the factors contributing to higher spending differed greatly within particular therapeutic categories. The results and their implications are discussed in the context of pharmaceutical policy environment.

Estimating medical costs of work-related diseases in the Basque Country (2008)

OBJECTIVES

To estimate the medical costs of work-attributable diseases (WAD) treated by the public health care system for one of the Spanish Autonomous Communities, the Basque Country, in 2008.

METHODS

We calculated the burden of disease attributable to work for each category of diseases according to ICD-9-CM by using estimates of attributable fractions. Hospital and specialized outpatient care cost data were derived from the Spanish National Health System analytical accountability system. Secondary sources of information were used to estimate primary health care and drug prescriptions.

RESULTS

Direct costs of work-attributable diseases borne by the Basque Regional Health Service totalled 106 million Euros in 2008, representing 3.3% of Basque public expenditures on health and 0.16% of Basque GDP in 2008. Specialized care, including hospitalizations, absorbed the highest proportion of costs (52%), followed by drug prescriptions and primary health care (27% and 21%, respectively). Diseases of the musculoskeletal system and connective tissues accounted for 47.3% of total costs, followed by cardiovascular diseases (19.6%) and cancer (15%).

CONCLUSIONS

Occupational diseases and accidents are costly in the Basque Region of Spain, generating a severe deviation of public expenditures and overburdening of the Public Health System because they should really be the responsibility of the Social Security System. Proper identification and assignment of costs of work-related diseases would result in significant savings for the National Health System (Spanish and European), would provide an incentive for the prevention of these avoidable causes of illness and thus contribute to the sustainability of social systems.

Cost-utility analysis of duloxetine in osteoarthritis: a US private payer perspective

BACKGROUND

Duloxetine has recently been approved in the USA for chronic musculoskeletal pain, including osteoarthritis and chronic low back pain. The cost effectiveness of duloxetine in osteoarthritis has not previously been assessed. Duloxetine is targeted as post first-line (after acetaminophen) treatment of moderate to severe pain.

OBJECTIVE

The objective of this study was to estimate the cost effectiveness of duloxetine in the treatment of osteoarthritis from a US private payer perspective compared with other post first-line oral treatments, including nonsteroidal anti-inflammatory drugs (NSAIDs), and both strong and weak opioids.

METHODS

A cost-utility analysis was performed using a discrete-state, time-dependent semi-Markov model based on the National Institute for Health and Clinical Excellence (NICE) model documented in its 2008 osteoarthritis guidelines. The model was extended for opioids by adding titration, discontinuation and additional adverse events (AEs). A life-long time horizon was adopted to capture the full consequences of NSAID-induced AEs. Fourteen health states comprised the structure of the model: treatment without persistent AE, six during-AE states, six post-AE states and death. Treatment-specific utilities were calculated using the transfer-to-utility method and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) total scores from a meta-analysis of osteoarthritis clinical trials of 12 weeks and longer. Costs for 2011 were estimated using Red Book, The Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project database, the literature and, sparingly, expert opinion. One-way and probabilistic sensitivity analyses were undertaken, as well as subgroup analyses of patients over 65 years old and a population at greater risk of NSAID-related AEs.

RESULTS

In the base case the model estimated naproxen to be the lowest total-cost treatment, tapentadol the highest cost, and duloxetine the most effective after considering AEs. Duloxetine accumulated 0.027 discounted quality-adjusted life-years (QALYs) more than naproxen and 0.013 more than oxycodone. Celecoxib was dominated by naproxen, tramadol was subject to extended dominance, and strong opioids were dominated by duloxetine. The model estimated an incremental cost-effectiveness ratio (ICER) of US$47,678 per QALY for duloxetine versus naproxen. One-way sensitivity analysis identified the probabilities of NSAID-related cardiovascular AEs as the inputs to which the ICER was most sensitive when duloxetine was compared with an NSAID. When compared with a strong opioid, duloxetine dominated the opioid under nearly all sensitivity analysis scenarios. When compared with tramadol, the ICER was most sensitive to the costs of duloxetine and tramadol. In subgroup analysis, the cost per QALY for duloxetine versus naproxen fell to US$24,125 for patients over 65 years and to US$18,472 for a population at high risk of cardiovascular and gastrointestinal AEs.

CONCLUSION

The model estimated that duloxetine was potentially cost effective in the base-case population and more cost effective for subgroups over 65 years or at high risk of NSAID-related AEs. In sensitivity analysis, duloxetine dominated all strong opioids in nearly all scenarios.

Tips for preparing for a 340B integrity audit

Key action steps hospitals and health systems can take to prepare for a 340B Drug Pricing Program integrity audit include the following: Conduct mock audits. Develop policies and procedures that specifically address the issues of patient eligibility, duplicate discounts, and appropriate Medicaid billing. Create a multidisciplinary team for 340B program oversight.

[Incidence, resource use and costs associated with postherpetic neuralgia: a population-based retrospective study]

AIM

To determine the incidence rate, the treatment administered and the use of health resources and health, and their respective costs in patients with postherpetic neuralgia (PHN).

PATIENTS AND METHODS

We performed an observational design, made from retrospective review of patient records from six primary care centers and one hospital. All patients > 30 years consulting for PHN between 1/1/2007 and 31/12/2010 were included. Prepared two study groups according to presence / absence of PHN. Follow up was for one year.

MAIN MEASURES

socio-demographic, treatment and co-morbidity. The cost model differed direct healthcare costs (primary care/specialist) and indirect (productivity).

STATISTICAL ANALYSIS

logistic regression models and analysis of covariance (p < 0.05).

RESULTS

1506 patients were recruited, age: 61.2 years female: 59.2%. 15.1% (n = 228, 95% CI = 8.1-22.1%) had a PHN (incidence rate: 0.8/1,000 inhabitants/year; 95% CI = 0.7-0.9/1,000 population/year), and increased with age (≥ 65 years: 19.7%). The PHN was principally associated with: psychosis (OR = 3.9), dementia (OR = 2.3), depression (OR = 1.8) and age (OR = 1.1), p < 0.03. Drugs use was higher (5.3 vs. 3.3; p < 0.001). The cost in primary care was 63.1% and 24.7% indirect. Total cost €1827.1 vs. €457.5 (p = 0.003), respectively, due to higher labour productivity losses (€692.2 vs. €62.4) and health costs (€1135 vs. €395.1); p < 0.001. All cost components maintained these differences.

CONCLUSIONS

PHN is a frequent complication. These patients have a significant economic burden. The cost increases with age.

[Survey of tumor necrosis factor inhibitors application in patients with rheumatoid arthritis in China]

OBJECTIVE

To investigate the current status of tumor necrosis factor (TNF) inhibitors application in rheumatoid arthritis (RA) patients in China and to analyze the related factors.

METHODS

A retrospective survey was conducted in 21 hospitals from different parts of China. The patients with RA were randomly enrolled. Data of their social backgrounds, clinical conditions, usage and adverse effects of TNF inhibitors were collected. The costs of TNF inhibitors and the indirect costs of the disease were calculated. A multivariate Logistic regression analysis was performed to analyze the factors related to TNF inhibitors application.

RESULTS

In the study, 1 095 RA patients from July 2009 to November 2010 were enrolled, of whom 112 had received TNF inhibitors, representing 10.2% of the total patients. The patients who received etanercept and infliximab were 7.4% (86/1 095) of the patients and 2.4% (26/1 095), respectively. There were 0.5% of the patients (5/1 095) who had received both of the TNF inhibitors. The patients who had accepted etanercept and treatment duration for less than 3 months and 3-6 months accounted for 38.5% and 25.0% respectively, while those treated with Infliximab were 38.1%. Their health assessment questionnaire (HAQ) scores were 1.1, 0.5 and 0.1, corresponding to treatment duration of infliximab for less than 3, 3-6 and 6-9 months and those were 1.3, 1.0, 0.3 corresponding to treatment duration of etanercept, respectively. Infliximab costs were RMB 24 525.0, 69 300.0 and 96 800.0 Yuan and etanercept costs were RMB 7 394.8, 9 158.6, 54 910.9 Yuan, respectively. Indirect costs for RA patients who accepted infliximab for less than 3, 3-6 and 6-9 months were RMB 365.6, 0 and 158.9 Yuan and those who accepted etanercept were RMB 2 158.4, 288.5 and 180.1 Yuan, respectively. Allergy and infection were the main side-effects of etanercept and both happened in 3.5% of all the patients. Liver damage happened in 2.3% of all the patients, while allergy and infection happened in 6.5% of all the patients who accepted infliximab. Logistic regression analysis showed that patients with higher education experience increased the odds of entering the TNF inhibitors group (OR: 1.292, 95%CI: 1.132-1.473, P=0.000).

CONCLUSION

About one-tenth of RA patients in China have accepted TNF inhibitors. Higher education experience is the key factor for using TNF inhibitors.

Americans' access to prescription drugs stabilizes, 2007-2010

Despite the weak economy and more people lacking health insurance, the proportion of Americans reporting problems affording prescription drugs remained level between 2007 and 2010, with more than one in eight going without a prescribed drug in 2010, according to a new national study from the Center for Studying Health System Change (HSC). While remaining stable overall, access to prescription drugs improved for working-age, uninsured people, likely reflecting a decline in visits to health care providers, as well as changes in the composition of the uninsured population. Likewise, elderly people eligible for both Medicare and Medicaid saw a sharp drop in prescription drug access problems. The most vulnerable people--the uninsured, those with low incomes, people in fair or poor health, and those with multiple chronic conditions--continued to face the most unmet prescription needs. For example, 48 percent of uninsured people in fair or poor health went without a prescription drug because of cost concerns in 2010, almost double the rate of insured people with the same reported health status.

Influence of patient payment on antibiotic prescribing in Irish general practice: a cohort study

BACKGROUND

Antibiotics are widely believed to be overused and misused. Approximately 80% of all prescriptions for antibiotics are written by GPs. There are many external factors that influence a GP's decision to prescribe, including patient pressure. Access to primary care services operates on a two-tier system in the Republic of Ireland: General Medical Service (GMS) card holders have free access to GPs and medications; and non-card holders (private patients) must pay a non-subsidised fee to visit their GP.

AIM

To ascertain whether there was a difference in antibiotic prescribing practice between those who pay a fee for their GP consultation and those who attend free of charge.

DESIGN AND SETTING

Cohort study in Irish general practice.

METHOD

All GPs attending continuing medical education (CME) groups nationwide were invited to participate from October 2008 until April 2010. GPs gathered data on 100 consecutive consultations including diagnosis and patient characteristics.

RESULTS

Data were collected from 171 GPs (distributed throughout Ireland), which resulted in 16 899 consultations. Antibiotics were prescribed at 3407 (20.16%) consultations. Nearly half of the prescriptions were for GMS card holders (n = 1669; 48.99%) and 1526 (44.79%) were for private patients; for 212 (6.22%) the payment status of the patient was unknown. Private patients were more likely to receive a prescription for antibiotics (odds ratio 1.23, 95% confidence interval = 1.14 to 1.33).

CONCLUSION

These results demonstrate that a GP's decision to provide a prescription for antibiotics may be influenced by whether or not the patient pays for their consultation at the GP interface. Private patients are more likely than GMS card holders to receive a prescription for antibiotics.

Drugs for rare diseases: influence of orphan designation status on price

The literature indicates that the expenditure on orphan drugs will be increasing over the coming years. The market for orphan drugs has inherent market characteristics that sometimes result in high prices. The aim of this study was to analyse whether awarding orphan designation status has an influence on the price setting of drugs for rare disease indications. To this effect, prices of designated orphan drugs were compared with other non-designated drugs for rare disease indications. We identified 28 designated orphan drugs and 16 comparable non-designated drugs for rare disease indications for which we collected official hospital prices (per defined daily dose) in Belgium in 2010. Orphan-designated drugs had a higher median price (138.56 Euros [interquartile range; IQR 406.57 Euros]) than non-designated drugs (16.55 Euros [IQR 28.05 Euros]) for rare disease indications (p < 0.01). In conclusion, our results suggest that awarding orphan designation status in itself is associated with higher prices for drugs for rare disease indications. In order to gain full insight into orphan drug pricing mechanisms, future research should focus on collecting information about the different factors influencing orphan drug pricing.

Risk for cost-related medication nonadherence among emergency department patients

OBJECTIVES

There has been a rapid rise in prescription drug costs over the past decade. As a result, many Americans are unable to afford their medications, especially in the current economic recession. Medication nonadherence is known to have adverse effects on health outcomes. The purpose of this study was to gain a preliminary understanding of cost-related medication nonadherence (CRMN) disclosure among screened emergency department (ED) patients and to describe the extent to which CRMN is associated with other economic and psychosocial risk factors.

METHODS

This was a prospective, cross-sectional study of a convenience sample of adult patients presenting to an urban academic ED with 61,962 annual visits in 2009. Nonemergent patients received an optional self-administered Social Health Survey between May and October 2009. Results were assessed from the sample of anonymous surveys that were completed and collected. Standard statistical methods were used to determine the frequencies and relative risks (RRs) for CRMN with 95% confidence intervals (CIs).

RESULTS

A total of 384 (25.5%) of the 1,506 adult patients who completed the survey either screened positive for any prior CRMN (20.7%) or disclosed concerns about affording medication (4.8%). Patients were significantly more likely to report risk for CRMN if they used tobacco (RR = 1.8, 95% CI = 1.5 to 2.2) or illicit drugs (RR = 2.0, 95% CI = 1.6 to 2.4), experienced intimate partner violence (IPV; RR = 1.8, 95% CI = 1.5 to 2.2), or reported concerns about overall financial instability (RR = 3.9, 95% CI = 3.2 to 4.7), food insufficiency (RR = 3.7, 95% CI = 3.1 to 4.3), housing problems (RR = 2.5, 95% CI = 2.1 to 2.9), and inadequate health insurance coverage (RR = 7.7, 95% CI = 6.2 to 9.5).

CONCLUSIONS

Risk for medication nonadherence due to cost concerns was identified in a quarter of nonemergent urban ED patients in our sample and was more likely to be reported by patients experiencing other economic and psychosocial risks. These findings indicate a need to include discussions about medication affordability and referrals to social services as part of ED discharge planning.

The impact of bariatric surgery on comorbidities and medication use among obese patients

BACKGROUND

The risks and benefits of bariatric surgery have rarely been evaluated in large multiyear patient samples. This study identifies the short- and long-term impact of bariatric surgery on comorbidities and medication use among obese patients.

METHODS

A comprehensive analysis of 5,502 obese patients who underwent bariatric surgery was performed. Submissions of reimbursement claims, including diagnostics and medication use, were compared in the 90 days preceding the surgery and 30 up to 1,110 days following the surgery. Presurgery and postsurgery frequency counts were performed on diagnostics and medication use to identify trends.

RESULTS

Among 5,502 patients, significant decreases in the prevalence of reported comorbidities were observed during the short-term postsurgery period and sustained for up to 3 years of follow-up. Compared to the presurgery period, significant decreases (p < 0.05) were observed after 3 years for total cardiovascular disorders (43.6% vs. 14.2%), diabetes mellitus (19.9% vs. 7.7%), chronic obstructive pulmonary disease and other respiratory conditions (57.7% vs. 16.2%), diseases of the musculoskeletal system and connective tissue (32.6% vs. 27.7%), and mental disorders (30.7% vs. 14.8%). Over the same period, the frequency of medication use decreased significantly for a number of conditions including infections, pain, respiratory, cardiovascular, gastroenterologic, lipidemic, and diabetic conditions. Anemia, however, increased from 3.8% to 9.9%, and use of nutritional supplements increased significantly.

CONCLUSION

Bariatric surgery was associated with significant reductions in reported claims for short- and long-term health outcomes and reduced medication use for major disease categories.

Disentangling incentives effects of insurance coverage from adverse selection in the case of drug expenditure: a finite mixture approach

This paper takes a finite mixture approach to model heterogeneity in incentive and selection effects of drug coverage on total drug expenditure among the Medicare elderly US population. Evidence is found that the positive drug expenditures of the elderly population can be decomposed into two groups different in the identified selection effects and interpreted as relatively healthy with lower average expenditures and relatively unhealthy with higher average expenditures, accounting for approximately 25 and 75% of the population, respectively. Adverse selection into drug insurance appears to be strong for the higher expenditure component and weak for the lower expenditure group.

Impact of drug cost sharing on service use and adverse clinical outcomes in elderly receiving antidepressants

BACKGROUND

Depression imposes enormous burdens on the elderly. Despite this, rates of initiation of and adherence to recommended pharmacotherapy are frequently low in this population. Although initiatives such as the Medicare Modernization Act (MMA) have improved seniors' access to antidepressants, there are concerns that the patient cost-sharing incorporated in the MMA may have unintended consequences if it reduces essential drug use. Age-related pharmacokinetic and pharmacodynamic changes could make seniors particularly vulnerable to antidepressant regimens used inappropriately to save costs, increasing their risks of morbidity, hospitalizations, and nursing home placements. Two sequential large-scale "natural experiments'' in British Columbia provide a unique opportunity to evaluate the effect of cost sharing on outcomes and mental health service use among seniors. In January 2002 the province introduced a CAD 25 copay (CAD10 for low-income seniors). In May 2003 this copay policy was replaced by a second policy consisting of an income-based deductible, 25% coinsurance once the deductible was met, and full coverage once an out-of-pocket ceiling was met. The transition between the two policies is analogous to what many U.S. seniors experience when they transition from private insurance requiring copays to Medicare Part D requiring deductibles and coinsurance.

AIMS

To evaluate whether declines in antidepressant initiation after the introduction of two drug cost-sharing policies in British Columbia were associated with increased use of physician services, hospitalizations, and nursing home admissions among all British Columbia residents aged 65+.

METHODS

Records of physician service use, inpatient hospitalizations, and residential care admissions were obtained from administrative databases. Population-level patterns over time were plotted, and effects of implementing the cost-sharing policies examined in segmented linear regression models.

RESULTS

Neither policy affected the rates of visits to physicians or psychiatrists for depression, hospitalizations with a depression diagnosis, or long-term care admissions.

DISCUSSION

The cost-sharing policies studied may have contained non-essential antidepressant use without substantially increasing mental health service utilization. However, it is possible that the policies had effects that we were unable to detect, such as increasing rates of visits to social workers or psychologists or forcing patients to reduce other spending. Further, the sequential implementation of the policy changes, makes it difficult to estimate the effect of a direct change from full coverage to a coinsurance/income-based deductible policy.

IMPLICATIONS FOR HEALTH POLICIES

It may be possible to design policies to contain non-essential antidepressant use without substantially increasing other service utilization or adverse events. However, because undertreatment remains a serious problem among depressed elderly, well-designed prescription drug policies should be coupled with interventions to address under-treatment.

[Evaluation of the quality of prescription and dispensing of artemisinin-based therapeutic combinations in the Bamako District, Mali]

The increasingly increasing resistance of the parasites of malaria to chloroquine pushed all the African countries almost to adopt the ACTs like treatment of first intention of uncomplicated malaria. However, correct use of the ACTs proves to be imperative to guarantee their effectiveness and to even delay the spread resistant parasites to these molecules. Thus, we have conducted this study in order to assess the quality of the prescription and the dispensation of ACTs in randomly selected health centers across Bamako. Our study was a cross-sectional study conducted between April and July 2008 with interview of patients received in clinic for malaria, a questionnaire was administered to physicians and other health workers who give prescription of antimalarials, and pharmacists and other people working in pharmacy or drugs deposit. In total, 52 prescribers, 72 dispensers and 92 patients were included. Our study has shown that the ACT constituted the treatment of first choice of malaria within prescribers (75%) and dispensers (78.8%). However, 57.61% of the prescriptions against malaria did not contain any ACTs. The ACTs recommended by the National Malaria Program (NMCP) were known by 59.7% of dispensers and 73.1% of prescribers. The majority of the prescribers (71.15%) and of the dispensers (84.72%) were favorable to the NMCP's recommendations. Many patients (41.30%) did not understand at all the dose of the prescribed ACTs. Almost all of the prescription containing ACT was a generic drug prescribed (97.72%; n = 44). The prices of the ACTs varied between 140 and 3,380 FCFA with an average of 750 FCFA. According to prescribers and dispensers, the ACT constitutes their first choice (75% of prescribers and 78.8% of the dispensers). However, 57.61% of the prescriptions against malaria did not contain any ACTs. The majority of prescribers (71.15%) and dispensers (84.72%) were favorable to the NMCP's recommendations of malaria treatment in Mali. The average cost of prescriptions containing ACT was 750 FCFA with the extreme ones going from 140 to 3,680 FCFA.

Exploring knowledge of prescription charges: a cross-sectional survey of pharmacists and the community

AIM

To determine the level of knowledge in the community, and the implications of recent changes to prescription prices that occurred in July 2007 in New Zealand.

METHOD

Two separate face-to-face surveys were conducted involving pharmacists (n=20) and the community (n=80).

RESULTS

In the community survey, 73.8% were unaware of the prescription price changes and 67.5% were unaware that the cost of prescriptions was prescriber-dependent. Cost was cited as a reason for not filling a script in the last 6 months by 8.75% of all respondents in the community survey. After being informed of the decreased prescription price, 28% stated that this change would increase the likelihood of seeing a doctor when they are ill. Pharmacists surveyed perceived that this change had decreased their profit, and 20% reported occasions on which patients had taken a specialist prescription to their GP to have rewritten in order to obtain the reduced primary health organisation (PHO) price.

CONCLUSIONS

This study showed that the majority of community participants were not aware of either the price change, or the prescriber-dependent access to cheaper prescriptions. This lack of knowledge could be a significant barrier to healthcare. It is critical that both the inequalities in access to cheaper medications are reviewed and that the complex pricing system is simplified to eliminate disparities between providers. Further, this study highlights the increasing role of GPs as gatekeepers to resources including reduced cost prescriptions.

Does a system of instalment dispensing for newly prescribed medicines save NHS costs? Results from a feasibility study

BACKGROUND

In view of the increasing cost of general practice of drug prescribing, it is important to look at ways of reducing drug wastage and thereby improve the cost-effectiveness of prescribing.

OBJECTIVE

To determine the costs and cost savings to the NHS of instalment dispensing for newly prescribed medicines and to quantify the extra costs incurred by patients.

METHODS

Patients were randomized to receive either a normal (n = 103) or an instalment (n = 101) prescription.

RESULTS

The difference between prescribed and dispensed drug costs in the intervention group was 0.98 UK pounds per patient (95% confidence interval 0.14-1.82 UK pounds), giving a 7% reduction in drug costs. The costs of the additional pharmacy time required to implement the intervention was calculated to be 5.02 UK pounds per patient.

CONCLUSIONS

Introduction of a system of instalment dispensing produced savings in the general practice of drugs bill, but these were not large enough to offset additional costs for pharmacists.

Racial and ethnic disparities in antidepressant drug use

BACKGROUND

Little is known about racial and ethnic disparities in health care utilization, expenditures and drug choice in the antidepressant market.

AIMS

This study investigates factors associated with the racial and ethnic disparities in antidepressant drug use. We seek to determine the extent to which disparities reflect differences in observable population characteristics versus heterogeneity across racial and ethnic groups. Among the population characteristics, we are interested in identifying which factors are most important in accounting for racial and ethnic disparities in antidepressant drug use.

METHODS

Using Medical Expenditure Panel Survey (MEPS) data from 1996-2003, we have an available sample of 10,416 Caucasian, 1,089 African American and 1,539 Hispanic antidepressant drug users aged 18 to 64 years. We estimate individual out-of-pocket payments, total prescription drug expenditures, drug utilization, the probability of taking generic versus brand name antidepressants, and the share of drugs that are older types of antidepressants (e.g., TCAs and MAOIs) for these individuals during a calendar year. Blinder-Oaxaca decomposition techniques are employed to determine the extent to which disparities reflect differences in observable population characteristics versus unobserved heterogeneity across racial and ethnic groups.

RESULTS

Caucasians have the highest antidepressant drug expenditures and utilization. African-Americans have the lowest drug expenditures and Hispanics have the lowest drug utilization. Relative to Caucasians and Hispanics, African-Americans are more likely to purchase generics and use a higher share of older drugs (e.g., TCAs and MAOIs). Differences in observable characteristics explain most of the racial/ethnic differences in these outcomes, with the exception of drug utilization. Differences in health insurance and education levels are particularly important factors in explaining disparities. In contrast, differences in drug utilization largely reflect unobserved heterogeneity across these population groups.

CONCLUSIONS

Substantive racial and ethnic disparities exist in all dimensions of antidepressant drug use examined. Observable population characteristics account for most of the differences in the expenditures, with health insurance and education key factors driving differences in spending. Observable characteristics are also important in explaining racial and ethnic disparities in the probability of purchasing generics and new vs old antidepressant drugs used. Differences in total utilization are not well-explained by observable characteristics, and may reflect unobserved heterogeneity such as unobserved physician-patient relationships, mistrust, and cultural factors.

IMPLICATIONS FOR POLICY

Reducing differences in observable characteristics such as health insurance and education will mitigate racial and ethnic disparities in expenditures on antidepressant drug use and in the types of antidepressant used (e.g., generics vs. brands; new vs old). But these factors will have less influence in reducing racial and ethnic disparities in overall antidepressant drug utilization. To limit differences in overall antidepressant drug use, policymakers must take into account cultural factors and other sources of heterogeneity.

What factors contribute to the inadequate control of elevated blood pressure?

Inadequate control of blood pressure may be attributed to both provider-related and patient-related factors. Health care provider-related factors may include an excessive reliance on monotherapy and reluctance to increase drug doses or add additional antihypertensive agents to the treatment regimen. The primary patient-related factor is nonadherence with the prescribed antihypertensive medication. Although the high cost of therapy is sometimes a reason for poor adherence, drug side effects or dosing considerations may be more important factors. Better adherence with antihypertensive medication is associated with a significantly greater likelihood of achieving blood pressure control and, consequently, with lower costs and reduced utilization of health care resources. Therefore, strategies that improve long-term adherence should be adopted. Single-pill, or fixed-dose, combination therapy is one approach that improves adherence, while also providing the antihypertensive efficacy needed to help patients achieve their blood pressure goals.

[Direct and indirect treatment cost of patient with ischaemic heart disease]

Authors of this paper attempted to evaluate the cost of treatment of hypothetical patient with ischaemic heart disease during the period 16 years. The medical costs (costs of medicines, diagnostic procedures, coronary angioplasty and bypass surgery) and indirect costs of lost productivity have been estimated.

Relationship of the magnitude of member cost-share and medication persistence with newly initiated renin angiotensin system blockers

BACKGROUND

Effective treatment for chronic diseases often requires medication refill persistence. Health plans have frequently increased the amount of member cost-sharing by implementing tier-copayment pharmacy benefit designs and raising copayments. However, increased member costshare may present a barrier to the management of chronic conditions. Little is known about the relationship between the magnitude of member cost-sharing and antihypertensive persistence among members newly initiating therapy.

OBJECTIVE

To investigate and quantify the relationship between amount of prescription cost-sharing and medication refill persistence among members newly initiating therapy with a single-agent angiotensin system blocker--either an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB).

METHODS

This was an observational cohort study of pharmacy and medical claims data for 29 employers with approximately 310,000 beneficiaries that did not have a change in pharmacy benefits including the amount of member cost-share in 2004. The claims data were supplemented with census data for household income and race at the Zip Code level. Selected patients were new users of single-agent ACEIs or ARBs (i.e., excluding ACEI or ARB in combination with hydrochlorothiazide or amlopdipine) between January 1 and June 30, 2004, without a pharmacy claim for an ACEI or an ARB in the 6 months prior to the index claim for either drug type. Medication refill persistence was measured in 3 ways: (1) total number of days without ACEIs or ARBs during 6 months follow-up, (2) proportion of days covered (PDC) with less than 80% defined as nonpersistent during 6 months follow-up, and (3) number of days to the first gap of more than 30 days in medication coverage from the index date to end of 2004 (mean [SD] follow-up=9.2 [1.8] months). Three statistical models were fit: Tobit model, examining the association between cost-sharing and total number of medication gap days; logistic regression, testing the association between cost-sharing and odds of being nonpersistent; and Cox proportional hazards model, assessing the association between cost-sharing and time to a 30-day gap.

RESULTS

Among the eligible population, a study cohort of 1,351 members newly initiating a single-agent ACEI or ARB was identified. These members were 41.8% female and had a mean age of 55.9 (SD=13.1) years. On average, their member cost-share was $12.42 (SD=$8.50) per 30-day supply. Each $1 increment in per 30-day cost-share was associated with a 1.9% increase in total gap (beta=0.019, 95% confidence interval [CI], 0.007-0.030, P=0.001), a 2.8% increase in the odds of being nonpersistent (odds ratio [OR]=1.028, 95% CI,1.011-1.045, P=0.001), and a 1.0% increase in the risk of having a gap of more than 30 days (hazard ratio [HR]=1.010, 95% CI, 1.001-1.019, P=0.034). Following transformation of the cost-sharing coefficient in each model, a $10 increment in cost-share had a consistent negative influence; 18.9% greater total gap days (beta=0.189, 95% CI, 0.073-0.304), 31.9% greater odds of being nonpersistent (OR=1.319, 95% CI, 1.120-1.553), and 10.2% larger hazard of having a gap of more than 30 days (HR=1.102, 95% CI, 1.007-1.205).

CONCLUSION

For members newly initiating single-agent angiotensin system blocking medication, the amount of prescription cost-sharing was associated with a negative impact on refill persistence.

The Medical License Number Accurately Identifies the Prescribing Physician in a Large Pharmacy Claims Database

BACKGROUND

Medical license numbers that identify physicians in pharmacy claims data are used increasingly for both research and quality improvement efforts; however, little is known about how well this information identifies the physician who wrote the prescription. We studied the accuracy of the medical license number in data from a state-run drug benefit plan by assessing its consistency with 2 external sources of data.

METHODS

We studied a cohort of new users of osteoporosis medications who participated in Medicare and a state-run pharmaceutical benefit program. The medical license number from the prescription data were merged with the American Medical Association's (AMA) Masterfile to determine if the physician on the pharmacy claim existed in the AMA directory and practiced in the area under study. The prescription data were then merged with Medicare Part B data to determine if the physician on the prescription had an outpatient visit with the patient who received the medication.

RESULTS

Of the 40,002 index prescriptions, 38,671 (96.7%) were written by physicians or doctors of osteopathy. Of those, 38,618 (99.9%) could be matched to the AMA Masterfile of which 37,375 (98%) had a local address. Of the AMA-matched prescriptions with a valid Unique Physician Identification Number (UPIN), 28,888 (96.1%) could be matched to Medicare Part B data, indicating that the physician whose license number appeared on the prescription had at least 1 outpatient visit with the patient who received the medication.

CONCLUSIONS

The state medical license number in the pharmacy claims dataset studied seems to identify the prescribing physician with a high degree of accuracy.

Effects of benefit design change across 5 disease states

OBJECTIVE

To assess the effects of benefit design change (BDC) on medication adherence and persistence (including switch in therapy), drug costs, and total healthcare costs.

STUDY DESIGN

A retrospective study was performed using administrative claims data from an integrated healthcare system between January 2001 and December 2002.

METHODS

Continuously enrolled patients in 2001 and 2002 with allergic rhinitis, asthma, diabetes mellitus, hypertension, or osteoarthritis belonged to employer groups with or without a pharmacy BDC as of January 1, 2002. Prescription status (same, switch, or discontinue), adherence among patients receiving therapy, and differences in drug costs and total healthcare costs for each disease state were measured between groups. Bivariate and multivariate statistics were used to test differences in outcomes between groups.

RESULTS

Compared with the group without BDC, the proportion of patients who discontinued drug therapy was significantly greater in the BDC group among those with allergic rhinitis (67% vs 54%), asthma (66% vs 50%), osteoarthritis (61% vs 36%), and hypertension (39% vs 18%) (P < .05 for all). Medication compliance was not affected by BDC. The year-to-year pharmacy costs per patient in the BDC group decreased $305 for patients with osteoarthritis (P < .001) and $95 for patients with allergic rhinitis (P = .03). There was no significant effect on overall healthcare costs in any disease state during the year following the BDC.

CONCLUSION

A pharmacy BDC may result in decreased pharmacy costs, with no effect on overall healthcare costs within 1 year for patients with allergic rhinitis, asthma, hypertension, or osteoarthritis.

Medication costs: the role physicians play with their senior patients

OBJECTIVES

To determine how often primary care physicians discuss medication costs with their senior patients and what cost-reducing strategies they employ.

DESIGN

Cross-sectional, random-sample mail questionnaire.

SETTING

State of California.

PARTICIPANTS

Six hundred seventy-eight of 1,098 (62%) internal medicine and family practice physicians selected from the American Medical Association Masterfile.

MEASUREMENTS

Main outcomes included frequency of cost discussions with senior patients in the previous 30 days and choice of cost-reducing strategy when a senior expresses financial difficulty with medication costs.

RESULTS

Forty-three percent of physicians reported discussing medication cost with at least half of their senior patients in the previous 30 days. Patients initiated most of these discussions. Forty percent reported that, at least one time in the previous 30 days, they had not discussed cost but wished they had. The most common reason given was "I ran out of time" (36%). Physicians with high perceived knowledge of medication costs were more likely to discuss cost (odds ratio (OR)=3.49, 95% confidence interval (CI)=1.66-7.3) versus low perceived knowledge, but this trend was not seen in physicians who scored high on actual knowledge of medication costs (OR=0.78, 95% CI=0.43-1.43) versus low actual knowledge. The most common cost-reducing strategies were generic substitution (33%) and offering samples (25%).

CONCLUSION

The frequency of medication cost discussions between physicians and senior patients is low, and when it occurs, is often initiated by patients. Physicians' perception of their knowledge of medication costs may be an important factor in initiating cost discussions.