Copayment Increase Research Articles

Evolutions in Both Co-Payment and Generic Market Share for Common Medication in the Belgian Reference Pricing System

In Belgium, a co-insurance system is applied in which patients pay a portion of the cost for medicines, called co-payment. Co-payment is intended to make pharmaceutical consumers more responsible, increase solidarity, and avoid or reduce moral hazards. Our objective was to study the possible influence of co-payment on sales volume and generic market share in two commonly used medicine groups: cholesterol-lowering medication [statins (HMG-CoA reductase inhibitors) and fibrates] and acid-blocking agents (proton pump inhibitors and histamine H2 receptor antagonists). The data were extracted from the Pharmanet database, which covers pharmaceutical consumption in all Belgian ambulatory pharmacies. First, the proportion of sales volume and costs of generic products were modelled over time for the two medicine groups. Second, we investigated the relation between co-payment and contribution by the national insurance agency using change-point linear mixed models. The change-point analysis suggested several influential events. First, the generic market share in total sales volume was negatively influenced by the abolishment of the distinction in the maximum co-payment level for name brands and generics in 2001. Second, relaxation of the reimbursement conditions for generic omeprazole stimulated generic sales volume in 2004. Finally, an increase in co-payment for generic omeprazole was associated with a significant decrease in omeprazole sales volume in 2005. The observational analysis demonstrated several changes over time. First, the co-payment amounts for name-brand and generic drugs converged in the observed time period for both medicine groups under study. Second, the proportion of co-payment for the total cost of simvastatin and omeprazole increased over time for small packages, and more so for generic than for name-brand products. For omeprazole, both the proportion and the amount of co-payment increased over time. Third, over time the prescription of small packages shifted to an emphasis on larger packages. As maximum co-payment levels decreased over time, they overruled the reference pricing system in Belgium. The changes in co-payment share over time also significantly affected sales volume, but whether physicians or patients are the decisive actors on the demand side of pharmaceutical consumption remains unclear.

Does the Association between Prescription Copayment Increases and Medication Adherence Differ by Race?

Previous studies have shown prescription copayment increases are associated with decreases in adherence to diabetes and hypertension medications, but have not investigated whether these associations differ by race. Veterans Affairs (VA) administrative data were used to analyze medication adherence before and after an increase in prescription copayments from $2 to $7 for a 30-day supply in February 2002. Applying a difference-in-difference approach, we compared adherence changes among White and Black veterans who were exempt from or required to pay medication copayments. The likelihood patients were adherent to diabetes or hypertension medications decreased after the copayment increase for both White and Black veterans. However, differences in medication adherence reductions between White and Black veterans were small and statistically insignificant. Despite barriers faced by minority patients related to lower perceived value of medications, the impact of a copayment increase on adherence was similar across the two largest racial groups in the VA.

Co-payments and the Use of Emergency Department Services in the Children’s Health Insurance Program

Research suggests that more than half of all emergency department (ED) visits in the United States are for nonurgent conditions, leading to billions of dollars in potentially avoidable spending annually. In this study, we examine the effects of co-payment changes on ED utilization among children enrolled in ALL Kids, Alabama's Children's Health Insurance Program We separately model the effect of the 2003 co-payment increases on the monthly probability of any ED visit, and visits within three severity categories, using linear probability models that control for beneficiary characteristics and time trends that are allowed to vary in the pre- and postperiods. We observe a small decline in the probability of ED visits 1 year after the co-payment increase. However, low-severity visits, which we hypothesize to be more price sensitive, show no significant evidence of a decline. Our study suggests that the modest co-payment changes were not effective in improving the efficiency of ED utilization.

Is the level of patient co-payment for medicines associated with refill adherence in Sweden?

In the Swedish reimbursement scheme, the co-payment is based on the price of the product and decreases in a stepwise manner as the total accumulated co-payment increases. The aim of this study was to analyse how refill adherence in Sweden varies according to patient's co-payment level for medicines, with antiepileptic drug (AED) use as an example. Prevalent AED users aged 18-85 years who purchased an AED between 1 January and 30 June 2007 were identified in the Swedish Prescribed Drug Register and followed for a maximum of 2 years. Patient time was categorized based on patient's accumulated co-payment for all drugs per reimbursement period. The continuous measure of medication acquisition (CMA) was used to estimate refill adherence in relation to the patients' co-payment level. Associations between patients' co-payment for all medicines and refill adherence were assessed with multilevel mixed-effects linear regression, accounting for clustering within patients. The study population included 2210 patients (mean age: 56 years; 54% men). CMA for AED was 91% for patients where the co-payment corresponded to 100% of the price. Compared with these patients, refill adherence for AED was 2-4% higher (P < 0.001) for patients with reduced co-payment (co-payment of ≤50% of the price). Higher age, higher income and fenytoin use were also associated with a higher refill adherence for AED. Using AED as an example, a higher level of reimbursement was associated with a higher refill adherence compared with full co-payment in Sweden.

Potential Bias in Medication Adherence Studies of Prevalent Users

We examined how the choice of historic medication use criteria for identifying prevalent users may bias estimated adherence changes associated with a medication copayment increase. From pharmacy claims data in a retrospective cohort study, we identified 6,383 prevalent users of oral diabetes medications from four VA Medical Centers. Patients were included in this prevalent cohort if they had one fill both 3months prior and 4-12months prior to the index date, defined as the month in which medication copayments increased. To determine whether these historic medication use criteria introduced bias in the estimated response to a $5 medication copayment increase, we compared adherence trends from cohorts defined from different medication use criteria and from different index dates of copayment change. In an attempt to validate the prior observation of an upward trend in adherence prior to the date of the policy change, we replicated time series analyses varying the index dates prior to and following the date of the policy change, hypothesizing that the trend line associated with the policy change would differ from the trend lines that were not. Medication adherence trends differed when different medication use criteria were applied. Contrary to our expectations, similar adherence trends were observed when the same medication use criteria were applied at index dates when no copayment changes occurred. To avoid introducing bias due to study design in outcomes assessments of medication policy changes, historic medication use inclusion criteria must be chosen carefully when constructing cohorts of prevalent users. Furthermore, while pharmacy data have enormous potential for population research and monitoring, there may be inherent logical flaws that limit cohort identification solely through administrative pharmacy records.

From the city to the bush: increases in patient co-payments for medicines have impacted on medicine use across Australia.

To determine whether the national declines in prescription medicine use occurring after the 2005 21% increase in co-payments affected all areas of Australia or were specific to remote and disadvantaged areas. Observed dispensing of proton pump inhibitors (PPIs) and statins were obtained for 1392 statistical local areas (SLA) of Australia in 2004 and 2006. Expected dispensing was based on national dispensing rates and was age standardised to each SLA. Expected dispensing for 2006 was based on pre-2005 prescription trends. Ratios of observed to expected dispensing (dispensing ratios) for each SLA were calculated. Mean dispensing ratios for each medicine and year were calculated for all remoteness and disadvantage groups. Generalised regression models compared the percentage change in dispensing ratios from 2004 to 2006. Between 2004 and 2006 PPI dispensing fell significantly in major cities (-13.7%, 95% CI=-17.3--9.8), inner regional (-14.0, 95%CI=-19.5--8.2), outer regional (-14.6%, 95%CI=-19.9--9.0) and remote areas (-9.4%, 95%CI=-16.4--1.8). Statin dispensing fell in all groups but the most remote (range 6-7%). When focussing on disadvantage, PPI dispensing fell significantly in all groups (range 12-15%). Statins dispensing did not fall significantly in the most disadvantaged areas (-2.9%, 95%CI=-8.6-3.2) but did in the least (-6.5%, -11.3--1.5) and second-least (-5.8, -10.5--0.9) disadvantaged areas. Dispensing of PPIs and statins in the most remote and disadvantaged areas remained substantially below levels expected for Australia after the 21% co-payments increase. The findings suggest that the 2005 21% in patient co-payments adversely affected prescription medicine use in all areas of Australia and was not specific to remote or disadvantaged areas. Indeed, dispensing of statins fell significantly in all but the most remote and disadvantaged areas, and the existing gap in dispensing of PPIs and statins was not widened by the co-payments increase. PPIs, which are used at above-prevalence rates in Australia and have cheaper over-the-counter substitutes available, were more sensitive to co-payment increases than were statins.

Primary non-adherence to prescribed medication in general practice: lack of influence of moderate increases in patient copayment

Primary non-adherence refers to the patient not redeeming a prescribed medication at some point during drug therapy. Research has mainly focused on secondary non-adherence. Prior to this study, the overall rate of primary non-adherence in general practice in Iceland was not known. To determine the prevalence of primary non-adherence, test whether it is influenced by a moderate increase in patient copayment implemented in 2010 and examine the difference between copayment groups (general versus concession patients). A population-based data linkage study, wherein prescriptions issued electronically by 140 physicians at 16 primary health care centres in the Reykjavik capital area during two periods before and after increases in copayment were matched with those dispensed in pharmacies, the difference constituting primary non-adherence (population: 200&emsp14;000; patients: 21&emsp14;571; prescriptions: 22&emsp14;991). Eight drug classes were selected to reflect symptom relief and degree of copayment. Two-tailed chi-square test and odds ratios for non-adherence by patient copayment groups were calculated. The rate of primary non-adherence was 6.2%. It was lower after the increased copayment, reaching statistical significance for hypertensive agents, non-steroidal anti-inflammatory drugs (NSAIDs) and antipsychotics. Generally, primary non-adherence, except for antibacterials and NSAIDs, was highest in old-age pensioners. Primary non-adherence in Icelandic general practice was within the range of prior studies undertaken in other countries and was not adversely affected by the moderate increase in patient copayment. Older patients showed a different pattern of primary non-adherence. This may possibly be explained by higher prevalence of medicine use.

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

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

당뇨병 환자의 동반상병 점수에 따른 상급종합병원 이용 차이

Some patients tend to visit tertiary hospitals instead of non-tertiary hospitals for minor illnesses, which is a chronic problem within the Korean health care delivery system. In order to reduce the number of patients with minor severity diseases unnecessarily utilizing the tertiary medical services in Korea, the Ministry of Health and Welfare raised the outpatient co-insurance rate for the tertiary hospitals in July, 2009. Another increase in the prescription drug co-insurance rate by the general and tertiary hospitals is scheduled to take place in the second half of 2011. An increase in copayments may discourage the utilization rate of medical services among the underprivileged or patients who require complicated procedures. This study aims to analyze the diabetic patients' utilization rates of tertiary hospitals according to the Comorbidity score. Diabetic patients' data was gathered from the Health Insurance Claims Records in the Health Insurance Review & Assessment Service between 2007-2009. Comorbidity scores are measured by the Charlson Comorbidity Index and the Elixhauser Index. Chi-square and logistic regressions were performed to compare the utilization rates of both insulin-dependents (n=94,026) and non-insulin-dependents (n=1,424,736) in tertiary hospitals. The higher Comorbidity outcomes in the insulin-dependent diabetic patients who didn't visit tertiary hospitals compared to those who did, was expected. However, after adjusting the gender, age, location, first visits and complications, the groups that scored >=1 on the comorbidity scale utilized the tertiary hospitals more than the O score group. Non-insulin-diabetic patients with higher Comorbidity scores visited tertiary hospitals more than patients who received lower grades. This study found that patients suffering from severe diabetes tend to frequently visit the tertiary hospitals in Korea. This result implied that it is important for Korea to improve the quality of its primary health care as well as to consider a co-insurance rate increase.

The effects of new pricing and copayment schemes for pharmaceuticals in South Korea

Objectives This study examined the effect of new Korean pricing and copayment schemes for pharmaceuticals (1) on per patient drug expenditure, utilisation and unit prices of overall pharmaceuticals; (2) on the utilisation of essential medications and (3) on the utilisation of less costly alternatives to the study medication. Methods Interrupted time series analysis using retrospective observational data. Results The increasing trend of per patient drug expenditure fell gradually after the introduction of a new copayment scheme. The segmented regression model suggested that per patient drug expenditure might decrease by about 12% 1 year after the copayment increase, compared with the absence of such a policy, with few changes in overall utilisation and unit prices. The level of savings was much smaller when the new price scheme was included, while the effects of a price cut were inconclusive due to the short time period before an additional policy change. Based on the segmented regression models, we estimate that the number of patients filling their antihyperlipidemics prescriptions decreased by 18% in the corresponding period. Those prescribed generic and brand-named antihyperlipidemics declined by around 16 and 19%, respectively, indicating little evidence of generic substitution resulting from the copayment increase. Few changes were found in the use of antihypertensives. Conclusions The policies under consideration appear to contain costs not by the intended mechanisms, such as substituting generics for brand name products, but by reducing patients’ access to costly therapies regardless of clinical necessity. Thus, concerns were raised about potentially compromising overall health and loss of equity in pharmaceutical utilisation.

HOW PRICE RESPONSIVE IS THE DEMAND FOR SPECIALTY CARE?

Outpatient visit co-payments have increased in recent years. We estimate the patient response to a price change for specialty care, based on a co-payment increase from $15 to $50 per visit for veterans with hypertension. A retrospective cohort of veterans required to pay co-payments was compared with veterans exempt from co-payments whose nonequivalence was reduced via propensity score matching. Specialty care expenditures in 2000-2003 were estimated via a two-part mixed model to account for the correlation of the use and level outcomes over time, and results from this correlated two-part model were compared with an uncorrelated two-part model and a correlated random intercept two-part mixed model. A $35 specialty visit co-payment increase had no impact on the likelihood of seeking specialty care but induced lower specialty expenditures over time among users who were required to pay co-payments. The log ratio of price responsiveness (semi-elasticity) for specialty care increased from -0.25 to -0.31 after the co-payment increase. Estimates were similar across the three models. A significant increase in specialty visit co-payments reduced specialty expenditures among patients obtaining medications at the Veterans Affairs medical centers. Longitudinal expenditure analysis may be improved using recent advances in two-part model methods.

Does Medication Adherence Following a Copayment Increase Differ by Disease Burden?

To compare changes in medication adherence between patients with high- or low-comorbidity burden after a copayment increase. We conducted a retrospective observational study at four Veterans Affairs (VA) medical centers by comparing veterans with hypertension or diabetes required to pay copayments with propensity score-matched veterans exempt from copayments. Disease cohorts were stratified by Diagnostic Cost Group risk score: low- (<1) and high-comorbidity (>1) burden. Medication adherence from February 2001 to December 2003, constructed from VA pharmacy claims data based on the ReComp algorithm, were assessed using generalized estimating equations. Veterans with lower comorbidity were more responsive to a U.S.$5 copayment increase than higher comorbidity veterans. In the lower comorbidity groups, veterans with diabetes had a greater reduction in adherence than veterans with hypertension. Adherence trends were similar for copayment-exempt and nonexempt veterans with higher comorbidity. Medication copayment increases are associated with different impacts for low- and high-risk patients. High-risk patients incur greater out-of-pocket costs from continued adherence, while low-risk patients put themselves at increased risk for adverse health events due to greater nonadherence.

The determinants of exit from institutions and the price elasticity of institutional care: Evidence from Japanese micro-level data

This study examines how the price mechanism affects the length of residents’ at institutions and their destination after exit. Using micro-level data from The Survey on Care Service Providers compiled by the Japanese government, we show that the price elasticity of the hazard of exit was 1.7 from welfare care facilities was 1.8 from health care facilities. Moreover, our estimates reveal that a 1 percentage point increase in copayments leads to an increase in the probability of returning home by 0.04% for residents of welfare care facilities and 3.7% for those of health care facilities and a decrease in the probability of being re-hospitalized by 3.3% for residents of health care facilities and 1.9% for those of medical care facilities. Our findings demonstrate that an appropriate price policy may work well to shorten clients’ length of stay and to reduce the number of the socially institutionalized.

Increasing Time Costs and Copayments for Prescription Drugs: An Analysis of Policy Changes in a Complex Environment

To estimate the effect of two separate policy changes in the North Carolina Medicaid program: (1) reduced prescription lengths from 100 to 34 days' supply, and (2) increased copayments for brand name medications. Medicaid claims data were obtained from the Centers for Medicare and Medicaid Services for January 1, 2000-December 31, 2002. We used a pre-post controlled partial difference-in-difference-in-differences design to examine the effect of the policy change on adults in North Carolina; adult Medicaid recipients from Georgia served as controls. Outcomes examined include medication adherence and Medicaid expenditures. Data were aggregated to the person-quarter level. Individuals in HMOs, nursing homes, pregnant, or deceased in the quarter were excluded. Both policies decreased medication adherence. The days' supply policy had a much larger effect on adherence than did the copayment increase. Total Medicaid spending declined from the days' supply policy, but the copayment policy resulted in a net increase in Medicaid expenditures. Although Medicaid costs decreased with the change in days supply policy, these savings were due to reduced adherence to these chronic medications. Additional research should examine the effect of these policy changes from the perspective of Medicaid enrollees.

Pharmaceutical Benefits Scheme cost sharing, patient cost consciousness and prescription affordability

To assess patients' prescription medicine cost consciousness and explore the implications of further cost sharing increases for affordability. A telephone interview survey of 818 randomly selected prescription medicine users (408 concession card holders, 410 general beneficiaries) resident in the Hunter Valley region of New South Wales, Australia. Degree of prescription cost consciousness; attitudes towards prescription use and cost sharing; self-rated capacity to manage further co-payment increases and differences between concession card holders and general beneficiaries in these measures. The majority of participants were cost conscious medicine users who act responsibly towards medicine use and believe that cost sharing is appropriate. Although there were no differences in cost consciousness scores, card holders appeared more sensitive to prescription costs and increases. Conversely, general beneficiaries were more likely to report difficulties with cost (avoiding seeing a doctor, not collecting prescription medicines, stopping or reducing the dose of a prescribed medicine). Although almost 75% of respondents reported that a co-payment increase would cause financial difficulty, only 28% indicated this would change their medicine use. These results suggest that most Australian patients are cost conscious but many are also close to facing difficulties with prescription costs. Further increases in PBS cost sharing could compromise prescription affordability, particularly for general beneficiaries.

Aromatase inhibitors: compliance decreases as copayments increase

Aromatase inhibitors: compliance decreases as copayments increase

Higher Co-Payments Increase Chance of Early Discontinuation of Breast Cancer Therapy

Higher Co-Payments Increase Chance of Early Discontinuation of Breast Cancer Therapy

Preventive Medicine: A Ready Solution for a Health Care System in Crisis

Preventive Medicine: A Ready Solution for a Health Care System in Crisis

On Utilization and Stockpiling of Prescription Drugs When Co-Payments Increase: Heterogeneity Across Types of Drugs

This paper investigates prescription drug utilization changes following an exogenous shift in consumer co-payment caused by a reform in the Danish subsidy scheme for the general public. Two different types of medication are considered – insulin for treatment of the chronic condition diabetes and penicillin for treatment of non-chronic conditions. Using purchasing records for a 20% random sample of the Danish population, I show that increasing co-payments lower the utilization of both drugs. I demonstrate that individuals treated with drugs for chronic conditions react to the policy change by stockpiling on their medications. This has implications for other papers in the literature that use variation in subsidy rates over time to estimate the price elasticity of demand. This is not the case for penicillin however, where price elasticities are estimated to be in the -.18 – -.35 range. Further, I find that the lower part of the income distribution is more price responsive.

Increased Ambulatory Care Copayments and Hospitalizations among the Elderly

When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care. We compared longitudinal changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans--similar plans that made no changes in these copayments. The study population included 899,060 beneficiaries enrolled in 36 Medicare plans during the period from 2001 through 2006. In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction. Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care.