Community financing of drug supplies in rural Nepal: evaluating a 'fee per item' drug scheme. Impact of 3-tier formularies on drug treatment of attention-deficit/hyperactivity disorder in children. The effect of drug co-payments on utilization and cost of pharmaceuticals in a health maintenance organization. Effect of a three-tier prescription copay on pharmaceutical and other medical utilization. The impact of implementing a more restrictive prescription limit on Medicaid recipients. Effects on cost, therapy, and out-of-pocket expenditures. Adverse events associated with prescription drug cost-sharing among poor and elderly persons. Effects of Medicaid drug-payment limits on admission to hospitals and nursing homes. The differential impact of copayment on drug use in a Medicaid population. Income-based drug benefit policy: impact on receipt of inhaled corticosteroid prescriptions by Manitoba children with asthma. Prescription drug utilization following patient co-payment changes in Australia. California's Medi-Cal copayment experiment. Medicaid spending and state cost control: assessing policy impact on drug expenditures. The effect of a copay increase on pharmaceutical utilization, expenditures, and treatment continuation. Impact of increasing the re-supply interval on the seasonality of subsidised prescription use in Australia. Impact of a cost sharing drug insurance plan on drug utilization among individuals receiving social assistance. The impact of outpatient drug benefits on the use and costs of health care services for the elderly. A time-series analysis of the effect of increased copayments on the prescription of antidepressants, anxiolytics, and sedatives in Sweden from 1990 to 1999. Can restrictions on reimbursement for anti-ulcer drugs decrease Medicaid pharmacy costs without increasing hospitalizations?
A new programme in rural Nepal was evaluated in which users partly fund the supply of additional drugs needed at health posts. Patients are charged a fee per item prescribed (FPI scheme). The scheme is administered by the District Public Health Office (DPHO). This scheme is compared with two established schemes: one charges patients a fee per prescription ('fee-per-script' or FPS scheme) and is administered by independently paid NGO (non-governmental organization) staff; the other uses local shops as a means of supplying drugs. The new scheme was associated with a rise in average daily attendance from nine to thirty-two patients a day (a 240% increase) when compared to a similar period the previous year. Fewer drugs were prescribed in the FPI scheme (average per patient 1.8 vs. 2.4, Chi square P <0.001). The average cost of a drug from the user's perspective was approximately 12% lower in the FPI scheme. These factors combined to make the average cost to the patient of a prescription half that of one in the FPS scheme. The new scheme was 24% cheaper to run on a 'cost per patient' basis when compared with the FPS scheme. However, the overall subsidy needed for the scheme to operate was higher because of the big increase in attendance. One-off stocktakes of ten essential drugs were used to assess the availability of drugs for patient use. The proportion of these drugs that were in low supply or absent was 24% in the FPI scheme. This was similar in the other two schemes. The government DPHO did not perform all the administrative tasks required. These tasks need to be simplified and different methods for involving DPHO staff in drug scheme management need to be explored. The rapid turnover of senior staff, however, will remain a major impediment. This preliminary evaluation shows that an FPI scheme promotes a more rational use of resources, compared to an FPS scheme. Administration of the scheme may, however, prove to be more difficult. A simple field-based comparative assessment of drug supply schemes can give a valuable insight into the strengths and weaknesses of a new programme. Expenditures for medications used to treat attention-deficit/hyperactivity disorder (ADHD) in children have increased rapidly. Many employers and health plans have adopted 3-tier formularies in an attempt to control costs for these and other drugs.
                To assess the effect of copayment increases associated with 3-tier formulary adoption on use and spending patterns for ADHD medications for children.
                Observational study using quasi-experimental design to compare effects on ADHD medication use and spending for children enrolled as dependents in an employer-sponsored plan that made major changes to its pharmacy benefit design and a comparison group of children covered by the same insurer. The plan simultaneously moved from a 1-tier (same copayment required for all drugs) to a 3-tier formulary and implemented an across-the-board copayment increase. The plan later moved 3 drugs from tier 3 to tier 2.
                An intervention group of 20 326 and a comparison group of 15 776 children aged 18 years and younger.
                Monthly probability of using an ADHD medication; plan, enrollee, and total ADHD medication spending; and medication continuation.
                A 3-tier formulary implementation resulted in a 17% decrease in the monthly probability of using medication (P<.001), a 20% decrease in expected total medication expenditures, and a substantial shifting of costs from the plan to families (P<.001). Intervention group children using medications in the pre-period were more likely to change to a medication in a different tier after 3-tier adoption, relative to the comparison group (P = .08). The subsequent tier changes resulted in increased plan spending (P<.001) and decreased patient spending (P = .003) for users but no differences in continuation.
                The copayment increases associated with 3-tier formulary implementation by 1 employer resulted in lower total ADHD medication spending, sizeable increases in out-of-pocket expenditures for families of children with ADHD, and a significant decrease in the probability of using these medications. This study analyzed how the use and cost of pharmaceuticals varied by level of drug co-payment in a staff model health maintenance organization (HMO). An historical cohort design was used to study changes in drug utilization and drug costs in 19,982 continuously enrolled beneficiaries less than the age of 65. The beneficiaries initially had no drug co-payments, but experienced co-payment rates of $1.50, $3.00, and $3.00 plus other benefit changes during a three-year period. A comparison cohort of 23,164 beneficiaries was selected from the same setting who were subject to no drug co-payment during the same time period. Data on the use and cost of medications were obtained from an automated data system. Adjusted analyses for each time period controlled for age, sex, years in the Group Health Cooperative (GHC), and prior year utilization (or cost). The initial $1.50 drug co-payment was associated with a drop of 10.7% in the number of prescriptions filled relative to change in the comparison cohort. The decrease was greatest for discretionary drugs at each level of co-payment. The implementation of progressively greater levels of co-payments continued to have a significant effect on drug utilization since each co-payment level resulted in an additional reduction in drug utilization; 10.6% with the $3 co-payment and 12.0% when the $3 drug co-payment was combined with other cost-sharing provisions. Co-payments were associated with lower per capita drug costs and higher per prescription unit costs. In response to rising prescription drug costs, plan sponsors are increasingly implementing three-tiered pharmacy benefits.
                This study examined the effect of a three-tiered pharmacy benefit on pharmaceutical utilization and expenditures, medication continuation, and use of other medical resources in a population of continuously eligible, commercially insured enrollees of a preferred provider organization (PPO).
                A quasi-experimental prepost with comparison group design was used. The pre- and postperiods were each 12 months long.
                The intervention group included enrollees whose employer moved from the PPO's two-tier benefit to a three-tier benefit (n = 6881). The comparison group included enrollees whose employer remained under the PPO's two-tier benefit (n = 13,279).
                Key dependent variables included total prescription claims and costs, net costs (total minus copay), medication continuation, office visits, and inpatient and emergency room use.
                Relative to the comparison group, the intervention group experienced lower prescription utilization and expenditures and reduced net costs. Medication continuation rates were lower at 6 and 11 months in one of four chronic therapy classes examined; however, discontinuation could not be clearly linked to tier-three medication use. No significant differences in physician office visits, inpatient, or emergency room use rates were found.
                Three-tier prescription copays can control drug costs without evidence of change in use of other medical resources in the year following implementation. Future research should examine a variety of three-tier designs. On November 1, 1991, the Georgia Department of Medical Assistance reduced the maximum number of monthly reimbursable prescriptions from six to five. This policy change provided a natural experiment to investigate the recipient responses to a decrease in an existing prescription limit. The research design was a quasiexperimental, retrospective, 12-month interrupted time-series analysis of a cohort. The cohort consisted of 743 ambulatory recipients who were high prescription users. Complete Medicaid claims data were obtained, in addition to pharmacy-generated computer profiles for all cohort recipients to determine Medicaid and out-of-pocket prescriptions expenditures. Interrupted time-series analyses were performed to model the effect of the five-prescription limit on total, Medicaid-reimbursed, out-of-pocket, and prescription use across eight therapeutic categories. After the implementation of the five-prescription limit, total prescription use fell 6.6%, prescriptions reimbursed by Medicaid fell 9.9%, and prescriptions paid for out-of-pocket increased 9.7%. Abrupt, permanent decreases were observed for cardiovascular, miscellaneous, pulmonary, and palliative therapeutic drug categories (alpha = 0.05), whereas gastrointestinal, chemotherapy, hormone (insulin), and central nervous system prescription use remained constant. The implementation of a more restrictive prescription limit alters prescription regimens potentially predisposing elderly Medicaid recipients to clinical consequences. Further examination of the health outcomes of these recipients is necessary. Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada. Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups.
                To determine (1) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and (2) rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation.
                Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events.
                A random sample of 93 950 elderly persons and 55 333 adult welfare medication recipients.
                Mean daily number of essential and less essential drugs used per month, ED visits, and serious adverse events (hospitalization, nursing home admission, and mortality) before and after policy introduction.
                After cost-sharing was introduced, use of essential drugs decreased by 9.12% (95% confidence interval [CI], 8.7%-9.6%) in elderly persons and by 14.42% (95% CI, 13.3%-15.6%) in welfare recipients; use of less essential drugs decreased by 15.14% (95% CI, 14.4%-15.9%) and 22.39% (95% CI, 20.9%-23.9%), respectively. The rate (per 10 000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8 [95% CI, 5.6-8.0]) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9 [95% CI, 10.2-15.5]). Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 (95% CI, 8.5-19.9) per 10 000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 (95% CI, 33.5-74.8) among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8). These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs. Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or ED visits.
                In our study, increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions. Many state Medicaid programs limit the number of reimbursable medications that a patient can receive. We hypothesized that such limitations may lead to exacerbations of illness or to admissions to institutions where there are no caps on drug reimbursements.
                We analyzed 36 months of Medicaid claims data from New Hampshire, which had a three-drug limit per patient for 11 of those months, and from New Jersey, which did not. The study patients in New Hampshire (n = 411) and a matched comparison cohort in New Jersey (n = 1375) were Medicaid recipients 60 years of age or older who in a base-line year had been taking three or more medications per month, including at least one maintenance drug for certain chronic diseases. Survival (defined as remaining in the community) and time-series analyses were conducted to determine the effect of the reimbursement cap on admissions to hospitals and nursing homes.
                The base-line demographic characteristics of the cohorts were nearly identical. In New Hampshire, the 35 percent decline in the use of study drugs after the cap was applied was associated with an increase in rates of admission to nursing homes; no changes were observed in the comparison cohort (RR = 1.8; 95 percent confidence interval, 1.2 to 2.6). There was no significantly increased risk of hospitalization. Among the patients in New Hampshire who regularly took three or more study medications at base line, the relative risk of admission to a nursing home during the period of the cap was 2.2 (95 percent confidence interval, 1.2 to 4.1), and the risk of hospitalization was 1.2 (95 percent confidence interval, 0.8 to 1.6). When the cap was discontinued after 11 months, the use of medications returned nearly to base-line levels, and the excess risk of admission to a nursing home ceased. In general, the patients who were admitted to nursing homes did not return to the community.
                Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs. In this study of the influence of copayment on drug utilization, we examined the prescription experience of 10 categories of drugs used by Medicaid beneficiaries in South Carolina over a four-year period. We observed an immediate and significant effect of copayment on the level of expenditures for all drug categories except analgesics and sedative/hypnotic drugs. The impact of copayment on the changes in the slopes of the series was not as dramatic. Only expenditures for cardiovascular, cholinergic, diuretic, and psychotherapeutic agents demonstrated a significant change in the long-term trend. We conclude that the imposition of a copayment for prescription services exerted a differential effect among therapeutic categories. Drug benefit policies are an important determinant of a population's use of prescription drugs. This study was undertaken to determine whether a change in a provincial drug benefit policy, from a fixed deductible and copayment system to an income-based deductible system, resulted in changes in receipt of prescriptions for inhaled corticosteroids by Manitoba children with asthma.
                Using Manitoba's health care administrative databases, we identified a population-based cohort of 10,703 school-aged children who met our case definition for asthma treatment before and after the province's drug benefit policy was changed in April 1996. The effects of the program change on the probability of receiving a prescription for an inhaled corticosteroid and on the mean number of inhaled corticosteroid doses dispensed were compared between a group of children insured under other drug programs (the comparison group) and 2 groups of children insured under the deductible program: those living in low-income neighbourhoods and those living in higher-income neighbourhoods. All analyses were adjusted for a measure of asthma severity.
                For higher-income children with severe asthma who were covered by the deductible program, the probability of receiving an inhaled corticosteroid prescription and the mean annual number of inhaled corticosteroid doses declined after the change to the drug policy. A trend toward a decrease in receipt of prescriptions was also observed for low-income children, but receipt of prescriptions was unaltered in the comparison group. Before the policy change, among children with severe asthma, the mean annual number of inhaled corticosteroid doses was lowest for low-income children, and this pattern persisted after the change. Among children with mild to moderate asthma, those covered by the deductible program (both low income and higher income) were less likely to receive prescriptions for inhaled corticosteroids than those in the comparison group, and this difference was statistically significant for the higher-income children.
                The change to an income-based drug benefit policy was associated with a decrease in the use of inhaled corticosteroids by higher-income children with severe asthma and did not improve use of these drugs by low-income children. In November 1990 major patient co-payment changes were introduced into the Pharmaceutical Benefits Scheme (PBS), which accounts for around 90% of all community prescriptions in Australia. Interrupted time series analyses were performed to assess the impact of these co-payment changes on the prescription levels of defined groups of 'discretionary' and 'essential' drugs for both the general community and for a subgroup comprising elderly returned servicemen and women. While the co-payment changes themselves had a significant immediate effect on lowering the use of both categories of drugs, the effects were substantially larger for the 'discretionary' groups in both cases. Notably there was a clear post-intervention trend for increased prescriptions of 'essential' drugs after the initial decline, which was not evident for the 'discretionary' drugs. The introduction of programmes to compensate high risk groups in Australia may have enabled the co-payment to become a more selective policy instrument than has been shown in other settings. nan This article introduces a new approach to the study of Medicaid policy and its role in state efforts to limit program costs. The approach is based upon recent work in the field of program evaluation, particularly in the areas of impact assessment and intervention modeling. To illustrate its use in evaluating program changes, the study focuses on policy reforms recently adopted by the state of Maryland as a means of cutting Medicaid expenditures for prescription drugs. Data on spending levels are taken from monthly claims reports filed with the federal government between January, 1974, and December, 1979. Preliminary findings indicate an abrupt decline in program costs following the introduction of new procedures for reimbursing drug providers and the automation of previous procedures for processing payment claims. No research has evaluated the impact of an increase to a copay that is reflective of today's healthcare market. This study examined the effect of an increase from a $10 to $15 copay for brand drugs on key pharmaceutical utilization measures, including participation rates, treatment continuation, and expenditures, in an adult population.
                A quasi-experimental, pre-post design with control group was used.
                Two different employer plans implemented an increase from $10 to $15 for brand copays in January of 1997. The utilization and expenditures of these plans were compared with those of a control group with a constant brand copay of $10 for 6 months preceding and 6 months following the copay increase.
                When other predictor variables were controlled for, the copay increase was not associated with a statistically significant difference in overall utilization compared with the control group, although brand utilization was significantly lower in the copay group. Savings to the payer were substantial, and resulted primarily from cost-shifting, reduction in brand utilization, and an increase in the generic fill rate. The rates of continuation with chronic medications in the 6 months following the copay increase were not reduced in the copay group compared with the control group.
                A copay increase can provide substantial savings to a payer without being a major deterrent to overall utilization or resulting in discontinuation of chronic medications. To evaluate the impact of increasing the minimum re-supply period for prescriptions on the Pharmaceutical Benefits Scheme (PBS) in November 1994. The intervention was designed to reduce the stockpiling of medicines used for chronic medical conditions under the PBS safety net.
                Interrupted times series regression analyses were performed on 114 months of PBS drug utilisation data from January 1991 to June 2000. These analyses assessed whether there had been a significant interaction between the onset of the intervention in November 1994 and the extreme levels of drug utilisation in the months of December (peak utilisation) and January (lowest utilisation) respectively. Both serial and 12-month lag autocorrelations were controlled for.
                The onset of the intervention was associated with a significant reduction in the December peak in drug utilisation; after the introduction of the policy there were 1,150,196 fewer prescriptions on average for that month (95% CI 708,333-1,592,059). There was, however, no significant change in the low level of utilisation in January. The effect of the policy appears to be decreasing across successive post-intervention years, though the odds of a prescription being dispensed in December remained significantly lower in 1999 compared to each of the pre-intervention years (11% vs. 14%).
                Analysis of the impact of increasing the re-supply period for PBS prescriptions showed that the magnitude of peak utilisation in December had been markedly reduced by the policy, though this effect appears to be decreasing over time. Continued monitoring and policy review is warranted in order to ensure that the initial effect of the intervention be maintained. A cost-sharing drug insurance plan has been implemented among people receiving social assistance who had previously free access to medications.
                To assess the impact of this drug plan on the use of three classes of medications: inhaled corticosteroids, neuroleptics and anticonvulsants.
                From the computerized drug databases of the Régie de l'assurance maladie du Québec (RAMQ), we selected three random samples of Quebec residents receiving social assistance between August 1992 and June 1997 and aged 64 years or less: 55890 users of inhaled corticosteroids, 29461 users of neuroleptics and 44916 users of anticonvulsants. We also obtained data for individuals privately insured by the Commission de la construction du Québec (control group). Comparison of the monthly consumption of medications before and after the new drug plan was done using time series models.
                For individuals receiving social assistance and using inhaled corticosteroids, we observed a statistically significant decrease of 37% of the monthly consumption for the 11 months following the new drug plan. For neuroleptics and anticonvulsants, we observed a non significant decrease of 9 and 10%, respectively. No decrease in drug consumption was observed in the control group.
                Inhaled corticosteroids was the only class of medications that was found to decrease significantly after the implementation of the drug insurance plan. In light of the current debate surrounding the extension of Medicare benefits to cover outpatient drugs, it is important to increase our understanding of the impact of drug payment programs on overall health care outcomes and expenditures. In this retrospective study of health care use among Medicare beneficiaries in New Jersey and eastern Pennsylvania, we studied the impact of New Jersey's Pharmaceutical Assistance for the Aged (PAA) program on health care costs. Using multiple regression analysis, we found that New Jersey Medicare recipients used, on average, $238.50 less in inpatient hospital care under the PAA program than did their counterparts in eastern Pennsylvania, which did not have a drug payment assistance program in place. Although administrative costs may have reduced overall savings, it seems reasonable to conclude that the PAA program resulted in no overall health care cost increases. Outpatient prescription medication spending in Sweden has increased sharply since 1974. The Swedish government has raised copayments to reduce medication consumption and limit the growth of medication spending.
                The aim of this study was to examine the effect of the 1995 and 1997 copayment increases on Swedish consumption of antidepressants, anxiolytics, sedatives.
                Monthly drug-use data for July 1990 through December 1999 for these 3 pharmaceutical classes were obtained from Apoteket AB (Stockholm, Sweden). Data were provided for both sexes in units of defined daily doses per 1000 inhabitants. These series were analyzed with the use of Box-Jenkins autoregressive, integrated, moving-average time-series modeling methods.
                Dispensing of all 3 drugs classes increased immediately before copayment changes, with the exception of male sedative use at the time of the 1997 reform. Permanent increases in male antidepressant and sedative use occurred before the 1995 copayment reform. Only female antidepressant use was permanently reduced following the 1997 copayment reform.
                Our findings suggest that Swedish patients' valuation of mental health medications exceeds the enacted price increases. The permanent increases in male antidepressant and sedative use, beginning in 1995, may have been the result of previous undertreatment. The permanent reduction in female antidepressant use, beginning in 1997, suggests that the price levels reached a threshold that matched or exceeded Swedish women's valuation of these modific To examine the impact of a policy restricting reimbursement for Medicaid anti-ulcer drugs on anti-ulcer drug use and peptic-related hospitalizations.
                In addition to U.S. Census Bureau data, all of the following from Florida: Medicaid anti-ulcer drug claims data, 1989-1993; Medicaid eligibility data, 1989-1993; and acute care nonfederal hospital discharge abstract data (Medicaid and non-Medicaid), 1989-1993.
                In this observational study, a Poisson multiple regression model was used to compare changes, after policy implementation, in Medicaid reimbursement for prescription anti-ulcer drugs as well as hospitalization rates between pre- and post-implementation periods in Medicaid versus non-Medicaid patients hospitalized with peptic ulcer disease.
                Following policy implementation, the rate of Medicaid reimbursement for anti-ulcer drugs decreased 33 percent (p < .001). No associated increase occurred in the rate of Medicaid peptic-related hospitalizations.
                Florida's policy restricting Medicaid reimbursement for anti-ulcer drugs was associated with a substantial reduction in outpatient anti-ulcer drug utilization without any significant increase in the rate of hospitalization for peptic-related conditions.
We found a diversity of cap and co-payment policies. Poor reporting of the intensity of interventions and differences in setting, populations and interventions made it difficult to make comparisons across studies. Cap and co-payment polices can reduce drug use and save plan drug expenditures. However, although insufficient data on health outcomes were available, substantial reductions in the use of life-sustaining drugs or drugs that are important in treating chronic conditions may have adverse effects on health, and as a result increase the use of healthcare services and overall expenditures. Direct payments are less likely to cause harm if only non-essential drugs are included or exemptions are built in to ensure that patients receive needed medical care.