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Drug co-payments, caps might deprive patients of needed
Medications
By Randy Dotinga, Contributing Writer
Health Behavior News Service
A new review of existing research suggests
that co-pays and caps on drug expenditures
could keep crucial medications out of the
hands of those who need them.
The review authors examined 21 studies that
looked at a variety of prescription drug
payment policies. Some had a cap, a maximum
number of prescriptions or drugs that are
reimbursed.
Others policies required a co-payment with
each prescription — a cost-sharing method
common in the United States where patients
pay a portion of the medication cost.
Among insurers that tried to keep costs down
through co-pays and caps, “reductions in
drug use were found for both life-sustaining
drugs and medications that are important in
treating chronic conditions,” said review
lead author Astrid Austvoll-Dahlgren, a
research fellow with The Norwegian Knowledge
Centre for the Health Services.
This could have “adverse effects” and lead
to higher costs to take care of patients who
end up getting sicker, Austvoll-Dahlgren
said.
By contrast, “policies in which people pay
directly for their drugs may be less likely
to cause harm” if only non-essential drugs
are included and if exemption safeguards are
built into the policy, she said.
At issue is the best way for insurers to pay
for medications. Should they encourage
patients to use cheaper and more
cost-effective drugs by instituting co-pays
and caps? Or is it better for insurers to
simply pay the full cost of medications?
The review appears in the latest issue of
The Cochrane Library, a publication of The
Cochrane Collaboration, an international
organization that evaluates medical
research. Systematic reviews draw
evidence-based conclusions about medical
practice after considering both the content
and quality of existing medical trials on a
topic.
Among the analyzed cost-sharing policies
some included co-pays and caps, others set
drug benefit ceilings in which patients pay
for their medications up to a certain
amount; above that level fees go down or
disappear. A few policies combined various
approaches.
One study examined a New Hampshire policy
that limited reimbursement to three
prescriptions for poor patients with chronic
disease. A 1977 policy, in South Carolina,
required a 50-cent co-pay for drug
prescriptions.
The studies suggest that caps and co-pays
reduced both the amount of medication used —
including life-sustaining drugs — and
medicine expenditures. However, the
researchers deemed the studies “generally
low to moderate” quality.
It is not clear if patient health suffered
under the cost-sharing policies. Few of the
studies looked at how the various payment
systems affected overall health.
The New Hampshire study found “adverse
effects” when the cap was introduced,
Austvoll-Dahlgren said, but other studies
did not find an impact.
Austvoll-Dahlgren said getting access to
medical records might have been a barrier to
a thorough analysis of the effects of drug
payment policies on health. Or, she said,
researchers may not consider the health
issue to be a priority.
The overall lesson, she said, is that
policies designed to make people shoulder
some of the cost of prescriptions could
potentially make people sicker.
But Austvoll-Dahlgren said there may be a
solution. “Policies in which people pay
directly for their drugs may be less likely
to cause harm if only non-essential drugs
are included in these policies or exemptions
are built into the policies to ensure that
people receive needed medical care.”
Richard Frank, a professor of health
economics at Harvard Medical School whose
research was mentioned in the review, said
the findings are not surprising: “Yes,
consumers do respond to prices.”
He said the most sensible strategy for
insurers may be to offer a tiered approach
that makes patients pay a smaller co-pay for
a generic drug and a larger amount for
brand-name drugs.
Frank said the best approaches “don’t force
people into either stopping things entirely
or making clinical decisions that are solely
based on dollars and cents.”
The worst money-saving strategies put limits
on the number of drugs that patients can get
or set limits on coverage, according to
Frank.
“They’ve been shown to not save that much
money and create lots of bad outcome. Across
the board, they’re not very nuanced, and
they tend to be more likely to get you in
trouble.”
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