Insurers Save Money with Co-Pays, Caps on Drugs But
Patients Endangered
Patients skip life-sustaining drugs, and those for
chronic conditions
By Randy Dotinga, Contributing Writer
Health Behavior News Service
Feb. 13, 2008 - 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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