Utilization of Essential Medications by Vulnerable Older People After a Drug Benefit Cap: Importance of Mental Disorders, Chronic Pain, and Practice Setting
01 Jun 2001-Journal of the American Geriatrics Society (J Am Geriatr Soc)-Vol. 49, Iss: 6, pp 793-797
TL;DR: To identify specific characteristics of patients, physicians, and treatment settings associated with decreased receipt of essential medications in a chronically ill, older population following a Medicaid three‐prescription monthly reimbursement limit (cap).
Abstract: OBJECTIVE: To identify specific characteristics of patients, physicians, and treatment settings associated with decreased receipt of essential medications in a chronically ill, older population following a Medicaid three-prescription monthly reimbursement limit (cap).
DESIGN: Quasi-experiment with bivariate and multivariate regression.
SETTING: Patients in the New Hampshire Medicaid program and their regular prescribing physicians.
PARTICIPANTS: Three hundred and forty-three chronically ill Medicaid enrollees with regular use of essential medications for heart disease, asthma/chronic obstructive pulmonary disease, diabetes mellitus, seizure, or coagulation disorders who received an average of three or more prescriptions per month during the baseline year.
MEASUREMENTS: Postcap patient-level change in standard monthly dose of essential medications compared with the baseline period, presence of 11 comorbidities (defined by regular use of specific indicator drugs), practice setting, and location of regular prescribing physician.
RESULTS: The mean percentage change in standard doses of essential medications following the cap was −34.4%. Larger changes were significantly associated with several baseline measures: greater numbers of precap medications, greater numbers of comorbidities, longer hospitalizations, and greater use of ambulatory services. The three comorbidities associated with the largest relative reduction in essential drug use were psychoses/bipolar disorders, anxiety/sleep problems, and chronic pain. Patients of physicians in group practices, clinics, or hospitals tended to have smaller dose reductions than those whose physicians were in solo or small-group practice.
CONCLUSIONS: Patients most at risk of reduced access to essential medications because of a reimbursement cap include those with multiple chronic illnesses requiring drug therapy, especially illnesses with a mental health component. Physicians in clinics or large group practices may have maintained patient medication regimens more effectively.
Citations
More filters
TL;DR: Pharmacy benefit design represents an important public health tool for improving patient treatment and adherence and increased cost sharing is highly correlated with reductions in pharmacy use, but the long-term consequences of benefit changes on health are still uncertain.
Abstract: ContextPrescription drugs are instrumental to managing and preventing chronic disease. Recent changes in US prescription drug cost sharing could affect access to them.ObjectiveTo synthesize published evidence on the associations among cost-sharing features of prescription drug benefits and use of prescription drugs, use of nonpharmaceutical services, and health outcomes.Data SourcesWe searched PubMed for studies published in English between 1985 and 2006.Study Selection and Data ExtractionAmong 923 articles found in the search, we identified 132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance (n = 65), pharmacy benefit caps or monthly prescription limits (n = 11), formulary restrictions (n = 41), and reference pricing (n = 16), and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.ResultsIncreased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.ConclusionsPharmacy benefit design represents an important public health tool for improving patient treatment and adherence. While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.
791 citations
TL;DR: The increasing prevalence of multimorbidity among older diabetic adults is at least in part an unintended consequence of success in improving diabetes treatment quality and may miss opportunities to improve patients’ functioning, quality of life, and mortality risk.
Abstract: Effective diabetes management often presents enormous challenges. Not surprisingly, clinicians and patients alike can be overwhelmed by the need to address comorbid chronic conditions in addition to patients’ diabetes-specific treatment goals. Ignoring concurrent disease management, however, can lead to ineffective control of diabetes-specific risk factors and may miss opportunities to improve patients’ functioning, quality of life, and mortality risk.
Other chronic conditions are common among people with diabetes and account for much of the morbidity these patients face. According to the Medical Expenditure Panel Survey, most adults with diabetes have at least one comorbid chronic disease (1) and as many as 40% have at least three (2,3). The increasing prevalence of multimorbidity among older diabetic adults is at least in part an unintended consequence of our success in improving diabetes treatment quality. Improvements in HbA1c (A1C) monitoring and glycemic control have been documented in several large systems of care (4–7). More widespread use of treatments such as ACE inhibitors and aspirin have decreased patients’ risk of cardiovascular death (8–10). Diabetic patients are living longer, and like all Americans, this increases their chance of acquiring one of the many chronic diseases associated with aging.
Other more troubling trends have conspired to increase the impact of multimorbidity on diabetes management. In many health care systems, providers see patients during brief office visits and are overwhelmed by the number of health maintenance activities recommended by guidelines and quality monitoring agencies (11,12). When diabetic patients have multiple chronic conditions, screening, counseling, and treatment needs can far exceed the time available for patient-provider visits. Health problems that used to be treated in inpatient settings are increasingly managed within outpatient care, further straining providers’ resources for addressing diabetes-specific management goals (13). With inadequate health system support and …
638 citations
TL;DR: Older patients with chronic diseases and mood disorders are at-risk for CRN even if enrolled in Medicare’s new drug benefit, and efforts to reduce cost-related medication nonadherence would benefit from greater study of factors besides the presence of prescription drug coverage.
Abstract: Objective
Up to 32% of older patients take less medication than prescribed to avoid costs, yet a comprehensive assessment of risk factors for cost-related nonadherence (CRN) is not available. This review examined the empirical literature to identify patient-, medication-, and provider-level factors that influence the relationship between medication adherence and medication costs.
364 citations
TL;DR: Clinicians should actively identify patients with diabetes who are facing medication cost pressures and assist them by modifying their medication regimens, helping them understand the importance of each prescribed medication, providing information on sources of low-cost drugs, and linking patients with coverage programs.
Abstract: OBJECTIVE—To identify problems faced by older adults with diabetes due to out-of-pocket medication costs. RESEARCH DESIGN AND METHODS—In this cross-sectional national survey of 875 adults with diabetes treated with hypoglycemic medication, respondents reported whether they had underused prescription medications due to cost pressures or had experienced other financial problems associated with medication costs such as forgoing basic necessities. Respondents also described their interactions with clinicians about medication costs. RESULTS—A total of 19% of respondents reported cutting back on medication use in the prior year due to cost, 11% reported cutting back on their diabetes medications, and 7% reported cutting back on their diabetes medications at least once per month. Moreover, 28% reported forgoing food or other essentials to pay medication costs, 14% increased their credit card debt, and 10% borrowed money from family or friends to pay for their prescriptions. Medication cost problems were especially common among respondents who were younger, had higher monthly out-of-pocket costs, and had no prescription drug coverage. In general, few respondents, including those reporting medication cost problems, reported that their health care providers had given them information or other assistance to address medication cost pressures. CONCLUSIONS—Out-of-pocket medication costs pose a significant burden to many adults with diabetes and contribute to decreased treatment adherence. Clinicians should actively identify patients with diabetes who are facing medication cost pressures and assist them by modifying their medication regimens, helping them understand the importance of each prescribed medication, providing information on sources of low-cost drugs, and linking patients with coverage programs.
288 citations
Cites background from "Utilization of Essential Medication..."
...Studies based on claims data (6,7) as well as surveys (8,9) demonstrate that some patients cut back on medication use because of cost pressures, and cost-related medication adherence problems have been linked to serious adverse health events (6,10–14)....
[...]
TL;DR: A systematic review of the effects of cost sharing on vulnerable populations (the poor and those with chronic illnesses) supports the view that cost sharing decreases the use of prescription drugs in these populations.
Abstract: Rising pharmaceutical expenditures have led to the use of cost-sharing measures. The authors undertook a systematic review of the effects of cost sharing on vulnerable populations (the poor and those with chronic illnesses). Virtually every article reviewed supports the view that cost sharing decreases the use of prescription drugs in these populations. Copayments or a cap on the monthly number of subsidized prescriptions lower drug costs for the payer, but any savings may be offset by increases in other health care areas. Cost sharing also leads to patients foregoing essential medications and to a decline in health care status.
186 citations
Cites background from "Utilization of Essential Medication..."
...Fortess and coworkers (15) noted that physicians working in group practices or clinics are somewhat more able to mitigate the effects of a cap on the number of monthly prescriptions than those practicing solo or in small groups....
[...]
...One way of possibly mitigating the effects of cost sharing on these groups would be to encourage physicians who serve large numbers of vulnerable patients to work in large group practices (15)....
[...]
...Medicaid beneficiaries have documented decreases in the use of essential medications as a result of monthly caps on the number of allowable prescriptions (15, 20, 26)....
[...]
...The groups analyzed were those with low income (social assistance, Medicaid, poor or near poor) (11–14, 17–24, 26–29, 31–34), those with significant health problems (poor health, chronically ill) (14, 16, 22, 25, 30), and the chronically ill poor (15)....
[...]
...Nevertheless, the conclusions of these studies were largely invariant with respect to the study design used: cross-sectional with regression-based adjustment for differences in subject characteristics (12, 16, 25, 31); before-and-after time series, with regression controls for secular time trends and other covariates (15, 17, 20, 23, 32, 33); or time series with an external comparison group not exposed to changes in drug prices that was thought to be otherwise similar to the group that was exposed (11, 18, 21, 26, 28)....
[...]
References
More filters
TL;DR: The hypothesis that the sedative and autonomic effects of psychotropic drugs increase the risk of falling and fractures in elderly persons is supported and the need for studies of this association in other populations is suggested.
Abstract: To assess the risk of hip fracture associated with the use of four classes of psychotropic drugs, we performed a case-control study of 1021 patients with hip fractures and 5606 controls among elderly Medicaid enrollees. Persons treated with hypnotics-anxiolytics having short (less than or equal to 24 hours) elimination half-lives had no increased risk of hip fracture. By contrast, a significantly increased risk was associated with current use of hypnotics-anxiolytics having long (greater than 24 hours) elimination half-lives (odds ratio, 1.8; 95 percent confidence interval, 1.3 to 2.4), tricyclic antidepressants (odds ratio, 1.9; 95 percent confidence interval, 1.3 to 2.8), and antipsychotics (odds ratio, 2.0; 95 percent confidence interval, 1.6 to 2.6). The risk increased in relation to the doses of drugs in these three classes. An analysis for possible confounding by dementia did not alter the results. Previous but noncurrent use of drugs in these classes conferred no increase in risk. Although a cause-and-effect relation was not proved, these data support the hypothesis that the sedative and autonomic effects of psychotropic drugs increase the risk of falling and fractures in elderly persons. The results suggest the need for studies of this association in other populations and for evaluation of newer psychotropic drugs with fewer undesirable sedative and autonomic effects.
921 citations
TL;DR: This article will focus on an under-recognised, and largely preventable drug related problem that is termed the “prescribing cascade”, which is an important area to target both to improve the quality of medical care for elderly people and to reduce the costs of health care for this population.
Abstract: The most frequent medical intervention performed by a doctor is the writing of a prescription. Because chronic illness increases with advancing age, older people are more likely to have conditions that require drug treatment. Advanced age, frailty, and increased use of drugs are all factors that contribute to a patient's risk of developing a drug related problem. As many as 28% of hospital admissions in the United States of older people are as a result of drug related problems,1 up to 70% of which are attributed to adverse reactions to drugs.1 Creating optimal drug regimens that meet the complex needs of elderly people requires thought and careful planning.
Inappropriate prescribing is expensive. In a recent study the costs of preventable adverse drug events—namely, injury resulting from a drug related medical intervention—occurring during a stay in hospital were estimated to be $2.8m (£1.75) annually in two large American teaching hospitals.2 The national cost of managing the consequences of inappropriate prescribing remains uncertain. One estimate has put the annual cost of drug related morbidity and mortality in outpatient clinics at $76.6bn.3 Drug related morbidity and mortality is an important area to target both to improve the quality of medical care for elderly people and to reduce the costs of health care for this population.
A prescriber can do little to modify age related physiological changes in trying to minimise the likelihood that an older person will develop an adverse drug reaction. However, when assessing a patient who is already taking drugs, a doctor should always consider the development of any new signs and symptoms as a possible consequence of the patient's drug treatment. This article will focus on an under-recognised, and largely preventable drug related problem that we have termed the “prescribing cascade.” 4 The prescribing cascade begins …
529 citations
TL;DR: Limiting reimbursement for effective drugs puts frail, low-income, elderly patients at increased risk of institutionalization in nursing homes and may increase Medicaid costs.
Abstract: Background. 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. Methods. 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. Results. The base-line demographic characteristics of the cohorts were nearly ide...
521 citations
TL;DR: Limits on coverage for the costs of prescription drugs can increase the use of acute mental health services among low-income patients with chronic mental illnesses and increase costs to the government, even aside from the increases caused in pain and suffering on the part of patients.
Abstract: Background We examined the effects of a three-prescription monthly payment limit (cap) on the use of psychotropic drugs and acute mental health care by noninstitutionalized patients with schizophrenia. We hypothesized that reducing access to such drugs would increase the use of emergency mental health services and the rate of partial hospitalizations (full-day or half-day treatment programs) and psychiatric-hospital admissions. Methods We linked Medicaid claims data for a period of 42 months with clinical records from two community mental health centers (CMHCs) and the single state psychiatric hospital in New Hampshire, where Medicaid imposed a three-prescription limit on reimbursement for drugs during 11 months (months 15 through 25) of the study. For comparison, we used Medicaid claims for a period of 42 months in New Jersey, which had no limit on drug reimbursement. The study patients (n = 268) and the comparison patients (n = 1959) were permanently disabled, noninstitutionalized patients with schizoph...
500 citations
TL;DR: A large number of Medicaid programs have implemented patient-level payment limits for medications, but the effects of these restrictions on quality of care, costs, and patient satisfaction are unclear.
Abstract: In an attempt to contain costs, 27 Medicaid programs have implemented patient-level payment limits for medications, but the effects of these restrictions on quality of care, costs, and health status remain largely unknown We measured the effect of one state's limit of three paid prescriptions per month and its replacement a year later by a $1 copayment Using data on 48 months of claims in the study state (New Hampshire) and a comparison state (New Jersey), we employed time-series analysis to evaluate patient-level changes in the number of prescriptions filled for 16 drugs that varied in their clinical importance and cost Among 10,734 continuously enrolled patients, the limit of three paid prescriptions per month caused a sudden, sustained drop of 30 percent in the number of prescriptions filled (from 110 to 077 prescriptions per patient per month); no change was observed in the comparison state The 860 recipients of multiple drugs, who were predominantly female and elderly or disabled, were
394 citations