Insurance Changes Alter Drug-Taking Behavior

Some patients stop taking medications, study finds

WEDNESDAY, Dec. 3, 2003 (HealthDayNews) -- Price matters, even when your health may be at stake.

Changes in prescription drug plans available to patients can alter how people use drugs, sometimes even causing them to stop taking certain drugs altogether, says a new study.

Despite easy inferences that such changes might be bad for your health, no one knows yet what effect this has on health-care quality or quality of life.

"When faced with a higher price, people sometimes will change drugs or discontinue therapy," says Cindy Parks Thomas, a senior scientist at the Schneider Institute for Health Policy at Brandeis University in Waltham, Mass. "It's still an unknown about how that discontinuation of therapy is affecting people." Thomas wrote a perspective article to accompany the study, both of which appear in the Dec. 4 issue of the New England Journal of Medicine.

According to Parks' article, prescription drug expenditures are the fastest-growing part of personal health care. To decrease their burden, employers and health-care plans recently started introducing "incentive-based formularies" to make consumers and doctors more sensitive to price and to shift more of the cost to consumers.

The three-tier plan is the most common of the incentive-based formularies. The first tier, typically for generic drugs, has the lowest co-pay ($10 or less). The middle tier, with a co-pay of $15 or more, is for brand-name drugs preferred by the organization (in other words, the plan may have negotiated rebate agreements with the manufacturer). The third and highest-priced tier ($25 or more) is for brand-name drugs not preferred by the organization.

During the past four years, the proportion of plans with three-tier formularies in the United States has jumped from 27 percent to 63 percent, Parks says. Some 57 percent of American workers are enrolled in a plan with a three-tier formulary. In addition, the new Medicare prescription drug legislation permits formularies, although no one knows yet what precise form these will take.

Previous studies have shown that formularies do result in lowering expenditures for insurers and employers, but no one knows whether they affect quality of and access to care.

The current study analyzed how consumers responded to the introduction of two different incentive-based formularies. Specifically, the researchers were interested in how the purchase of ACE inhibitors, statins and proton-pump inhibitors (for acid reflux) were affected.

The first plan switched from a one-tier to a three-tier formulary at the same time it increased all co-payments for medications.

The second plan made a less dramatic change, switching from a two-tier to a three-tier formulary and only changing the co-payments for tier-3 drugs.

Enrollees in both plans made changes, though they were more pronounced in the plan with the more dramatic changes. Many members of the first plan did switch to less expensive tier-1 or tier-2 drugs and some enrollees stopped taking medications altogether. The changes in the second plan resulted in few changes in the use of a drug.

"We definitely saw that these financial incentives did influence prescribing and taking, but we can't say with this kind of data what the long-term impact on health will be," says study author Haiden Huskamp, an assistant professor of health economics at Harvard Medical School. "Certainly, some flags were raised with the findings, for example, statins, but we can't say definitively."

Still, the picture is slowly coming into focus.

"We're beginning to get a consensus on the fact that these formularies and approaches can slow the rates of growth of prescription drug expenditures and that they also have other consequences, like shifting some of the costs to patients and perhaps causing, in their most extreme form, some patients to stop taking their drugs," Thomas says. "Now we need to take that next step and look at who is eliminating medications. If it's only people taking it on a 'discretionary' basis or who are very borderline, it could be a good thing."

Huskamp already has a head start looking at the health bottom line. She is working with members of the same team to see exactly who is stopping and switching medications. The assignment is a tough one because often no negative effects are seen until years after changing or discontinuing a medication.

More information

Visit Medicare for more on the recent prescription drug legislation. For the industry perspective on prescription drugs, visit the Pharmaceutical Research and Manufacturers of America.

SOURCES: Haiden Huskamp, Ph.D., assistant professor, health economics, Harvard Medical School, Boston; Cindy Parks Thomas, Ph.D., senior scientist, Schneider Institute for Health Policy, Brandeis University, Waltham, Mass.; Dec. 4, 2003, New England Journal of Medicine
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