Retrospective, Long-Term Follow-Up Study of the Effect of a Three-Tier Prescription Drug Copayment System on Pharmaceutical and Other Medical Utilization and Costs

Express Scripts, Inc, Maryland Heights, Missouri 63043, USA.
Clinical Therapeutics (Impact Factor: 2.73). 12/2003; 25(12):3147-61; discussion 3144-6. DOI: 10.1016/S0149-2918(03)90099-3
Source: PubMed


Previous research has suggested that 3-tier prescription drug copayment systems produce drug cost savings without affecting the use of other medical services during the first 12 months after implementation. Assessment of such systems with a longer follow-up period has been needed.
This study examined the effect of a 3-tier copayment system on pharmaceutical and medical utilization and cost for 30 months after implementation in a population of commercially insured, preferred-provider organization members.
This was a quasi-experimental, pre-post with comparison group design that gathered data retrospectively from the claims database of a preferred-provider organization in the Midwestern United States. The intervention group comprised members whose employer switched from a 2-tier (generic/brand copayment) plan to a 3-tier (generic/formulary/nonformulary) plan. The comparison group comprised members whose employer retained the 2-tier plan. Employers did not offer a choice between the 2- and 3-tier plans. Outcome measures included total drug cost; net insurer cost (drug cost minus copayment); number of prescription claims; numbers of office visits, inpatient hospitalizations, and emergency department visits; and rates of continuation with chronic medication therapy.
Relative to the comparison group (n=4132), the intervention group (n=3577) showed reduced growth in net cost and lower utilization of third-tier (nonformulary) medications (P<0.001 and P<0.01, respectively). The intervention and comparison groups did not differ significantly with respect to numbers of office visits, emergency department visits, or inpatient hospitalizations. Medication continuation rates were lower for the intervention than the comparison group at 6 months for oral contraceptives (P<0.05), but chronic medication therapy continuation rates did not differ significantly at any other time point or for estrogens, antihypertensives, or antihyperlipidemics.
In the population studied, previous research findings were confirmed over a longer time period.

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    • "When persistence was evaluated, higher cost sharing had no effect (5 studies)[15,23,56,59,79] or mixed effects (1 study). [63], with only one study finding that higher cost sharing negatively impacted medication continuation. "
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    ABSTRACT: Maintaining quality of care while managing limited healthcare resources is an ongoing challenge in healthcare. The objective of this study was to evaluate how the impact of drug management programs is reported in the literature and to identify potentially existing quality standards. This analysis relates to the published research on the impact of drug management on economic, clinical, or humanistic outcomes in managed care, indemnity insurance, VA, or Medicaid in the USA published between 1996 and 2007. Included articles were systematically analyzed for study objective, study endpoints, and drug management type. They were further categorized by drug management tool, primary objective, and study endpoints. None of the 76 included publications assessed the overall quality of drug management tools. The impact of 9 different drug management tools used alone or in combination was studied in pharmacy claims, medical claims, electronic medical records or survey data from either patient, plan or provider perspective using an average of 2.1 of 11 possible endpoints. A total of 68% of the studies reported the impact on plan focused endpoints, while the clinical, the patient or the provider perspective were studied to a much lower degree (45%, 42% and 12% of the studies). Health outcomes were only accounted for in 9.2% of the studies. Comprehensive assessment of quality considering plan, patient and clinical outcomes is not yet applied. There is no defined quality standard. Benchmarks including health outcomes should be determined and used to improve the overall clinical and economic effectiveness of drug management programs.
    BMC Health Services Research 03/2009; 9(1):38. DOI:10.1186/1472-6963-9-38 · 1.71 Impact Factor
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    • "However, our findings concur with previous reviews in managed care and other settings that these interventions may also be associated with undesirable effects such as increased rates of switching to other medications or discontinuation of essential and cost-effective medications [3,48,82,83]. In addition, some studies reported changes in measures such as hospitalization or medical resource utilization (e.g. office visits) resulting from formulary-related interventions [44,45,49,50,70]. "
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    ABSTRACT: Managed care organizations use a variety of strategies to reduce the cost and improve the quality of medication use. The effectiveness of such policies is not well understood. The objective of this research was to update a previous systematic review of interventions, published between 1966 and 2001, to improve the quality and efficiency of medication use in the US managed care setting. We searched MEDLINE and EMBASE for publications from July 2001 to January 2007 describing interventions targeting drug use conducted in the US managed care setting. We categorized studies by intervention type and adequacy of research design using commonly accepted criteria. We summarized the outcomes of well-controlled strategies and documented the significance and magnitude of effects for key study outcomes. We identified 164 papers published during the six-year period. Predominant strategies were: educational interventions (n = 20, including dissemination of educational materials, and group or one-to-one educational outreach); monitoring and feedback (n = 22, including audit/feedback and computerized monitoring); formulary interventions (n = 66, including tiered formulary and patient copayment); collaborative care involving pharmacists (n = 15); and disease management with pharmacotherapy as a primary focus (n = 41, including care for depression, asthma, and peptic ulcer disease). Overall, 51 studies met minimum criteria for methodological adequacy. Effective interventions included one-to-one academic detailing, computerized alerts and reminders, pharmacist-led collaborative care, and multifaceted disease management. Further, changes in formulary tier-design and related increases in copayments were associated with reductions in medication use and increased out-of-pocket spending by patients. The dissemination of educational materials alone had little or no impact, while the impact of group education was inconclusive. There is good evidence for the effectiveness of several strategies in changing drug use in the managed care environment. However, little is known about the cost-effectiveness of these interventions. Computerized alerts showed promise in improving short-term outcomes but little is known about longer-term outcomes. Few well-designed, published studies have assessed the potential negative clinical effects of formulary-related interventions despite their widespread use. However, some evidence suggests increases in cost sharing reduce access to essential medicines for chronic illness.
    BMC Health Services Research 02/2008; 8(1):75. DOI:10.1186/1472-6963-8-75 · 1.71 Impact Factor
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    • "Most studies found that higher cost sharing lowered total prescription drug expenditure. Expenditure reductions ranged from a non-significant 0.04% of total prescription drug expenditure when moving from a two-tier to a three-tier formulary [23] to 58% of expenditure on ACE inhibitors when moving from a one-tier to a two-tier formulary [24]. Variation in the magnitude of expenditure reductions was influenced by contextual factors such as the size of the increase in user charges, the type of drugs associated with user charges, and the population groups subject to user charges. "
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    ABSTRACT: As pharmaceutical expenditure continues to rise, third-party payers in most high-income countries have increasingly shifted the burden of payment for prescription drugs to patients. A large body of literature has examined the relationship between prescription charges and outcomes such as expenditure, use, and health, but few reviews explicitly link cost sharing for prescription drugs to efficiency and equity. This article reviews 173 studies from 15 high-income countries and discusses their implications for important issues sometimes ignored in the literature; in particular, the extent to which prescription charges contain health care costs and enhance efficiency without lowering equity of access to care.
    International Journal for Equity in Health 02/2008; 7(1):12. DOI:10.1186/1475-9276-7-12 · 1.71 Impact Factor
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