Effect on drug utilization and expenditures of a cost-share change from copayment to coinsurance.
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BACKGROUND: While increases in prescription drug spending have moderated in recent years, drug spending is still a concern among managed care organizations and health plan administrators. In order to minimize cost increases from year to year, many health care plans have shifted more of the cost of medications to the member-consumer. Coinsurance, a benefit design in which the patient pays a percentage of the cost of the medication, is garnering more attention as a type of cost-sharing that differs from the traditional copayment model. OBJECTIVE: To estimate the impact on medication expenditures and utilization of a pharmacy benefit design change from 3-tier copayment to coinsurance. METHODS: Drug expenditures and utilization of beneficiaries aged >or =18 years and continuously enrolled in 2 privately insured groups were compared before and after a benefit design change in 1 of the groups. For the 12 months before the benefit design change, both groups had a 3-tier, fixed-dollar copayment structure with identical cost-sharing per 30-day supply: $10 tier-1 copayment for generic drugs, $25 tier-2 copayment for preferred brand drugs, and $40 tier-3 copayment for non-preferred brand drugs. On September 1, 2005, a 4-tier coinsurance benefit design (25% for all tiers except tier-3 [non-preferred] drugs at 50%, with minimum and maximum patient out-of-pocket [OOP] cost applied to each tier) was implemented in the intervention group (N = 46,311). The 3-tier copayment design was maintained in the comparison group (N = 7,916). A difference-in-difference analysis was used to estimate the effect of the benefit design change on expenditures and utilization, overall (for all prescription drugs), and for 3 classes of essential medications: antihypertensives, antidepressants, and statins. Analyses measured changes in outcomes from 6 months pre-change (October 1, 2004, through March 31, 2005) through 6 months post-change (October 1, 2005, through March 31, 2006). In the overall (all drug) analyses, per member per month (PMPM) outcome measures were total pharmacy claims and cost, beneficiary (patient OOP) cost, and employer (plan sponsor) cost. Analyses of the 3 essential drug classes were limited to members with at least 1 claim in the drug class in both the pre-change and post-change periods (N = 11,917, intervention group; 1,792, comparison group), and assessed per patient per month (PPPM) days supply, beneficiary cost, employer cost, and total cost. RESULTS: Beneficiaries in the intervention group paid 31.8% of total pharmacy benefit cost at the point of care versus 31.5% in the comparison group in the post-change period. The increases in beneficiary cost from the pre-change period to the post-change period were not significantly different for the intervention (7.5%) and comparison (3.0%) groups (P = 0.983). From the pre-change period to the post-change period, total spending per member increased $4.57 PMPM (6.3%), from $72.29 to $76.87 in the intervention group versus a $5.87 PMPM increase (9.5%), from $61.54 to $67.41, in the comparison group, a relative difference of $1.30 PMPM (P = 0.013). The increases in utilization from the pre-change period to the post-change period were not significantly different in the intervention group (2.4%) versus the comparison group (4.6%, P = 0.189). Utilization per patient in the 3 essential drug classes increased 4.1% (1.59 days PPPM) in the intervention group versus 9.0% (3.23 days PPPM) in the comparison group (P = 0.004). Total expenditures in the 3 classes for the intervention and comparison groups increased 8.2% ($5.07 PPPM) and 13.3% ($7.80 PPPM), respectively, a difference of $2.73 PPPM (P = 0.003). Beneficiary cost for all 3 drug classes increased $2.20 PPPM (9.2%) in the intervention group versus $2.12 PPPM (9.1%) in the comparison group (P = 0.032). The increases in employer cost for the 3 essential drug classes in the intervention group (7.5%, $2.86 PPPM) and comparison group (16.1%, $5.67 PPPM) did not significantly differ (P = 0.057). CONCLUSIONS: A pharmacy benefit design change from tiered copayment to tiered coinsurance, without a significant increase in beneficiary OOP costs, was associated with a lower rate of increase in total pharmacy benefit cost and no significant reduction in utilization. For utilizers in 3 essential drug classes, drug utilization and total spending increased in the coinsurance group but at a lower rate of increase compared with the copayment group. The coinsurance design provides another approach for controlling prescription utilization and spending for certain medication classes. (+info)
Utilization, cost trends, and member cost-share for self-injectable multiple sclerosis drugs--pharmacy and medical benefit spending from 2004 through 2007.
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BACKGROUND: In 1993, interferon beta-1b became the first of 4 self-injectable multiple sclerosis (MS) drugs to be approved by the U.S. Food and Drug Administration. Initially covered as a medical expense, self-injectable MS drugs are increasingly considered specialty pharmaceuticals and are often covered under the pharmacy benefit. Self-injectable MS drugs are expensive, costing approximately $2,000 per month per patient in 2007. OBJECTIVES: To (1) determine the trends for price and utilization of self-injectable MS drugs, (2) meld medical and pharmacy claims data to capture total health care spending on self-injectable MS drugs, and (3) calculate the out-of-pocket cost-share for members with pharmacy benefits. METHODS: A pharmacy benefits manager with integrated medical claims for approximately 1.8 million commercial members, about 20% of its total of 9 million commercial members, analyzed self-injectable MS pharmacy claims for a 45-month period beginning in January 2004 and ending in September 2007 and integrated medical and pharmacy claims for a 42-month period beginning in January 2004 and ending in June 2007. The 9 million members are beneficiaries of 10 Blue Cross Blue Shield (BCBS) health plans distributed throughout the United States, and the subset of 1.8 million members are enrolled in 1 BCBS health plan in the Northern Plains states. Self-injectable MS drugs were identified using Generic Product Identifier (GPI) codes for the National Drug Code (NDC) numbers on pharmacy claims. Mail order pharmacy claims with up to a 90-day supply were counted as 3 claims, and community pharmacy claims dispensed with up to a 34-day supply were counted as 1 claim. Self-injectable MS drugs were identified from medical claims using Healthcare Common Procedure Coding System (HCPCS) codes: J1595 for glatiramer, J1830 for subcutaneous interferon beta-1b, Q3026 for subcutaneous interferon beta-1a, and Q3025 and J1825 for intramuscular interferon beta-1a. RESULTS: For the approximately 9 million members with data from pharmacy claims only, these 4 self-injectable MS drugs accounted for approximately 1.8% of total pharmacy benefit spending in 2004, 1.9% in 2005, 2.3% in 2006, and 2.4% in 2007. The mean average wholesale price (AWP) per member per month (PMPM) increased by 56.8%, from $1.11 PMPM in the first quarter of 2004 to $1.74 PMPM in the third quarter of 2007. Utilization was flat at about 82-83 claims per 100,000 members per month during the 45-month measurement period. The average annual price increase per unit ranged from 8.9% for interferon beta-1a to 13.3% per year for interferon beta-1b. Members paid a median out-of-pocket cost per pharmacy claim of $15 in 2004, $20 in 2005 and 2006, and $25 in the first 9 months of 2007. For the 1.8 million members with both pharmacy and medical benefit claims, the medical benefit accounted for 2.5% of total spending on MS self-injectables in 2004, 2.0% in 2005 and 2006, and 1.2% in 2007. CONCLUSION: The percentage of all pharmacy expenditures that was attributable to self-injectable MS drugs increased from 1.8% in 2004 to 2.5% in 2007. Nearly all of the increase in spending on self-injectable MS drugs over the nearly 4-year period was attributable to drug price increases because PMPM utilization was essentially unchanged. The median member cost-share was approximately 1% of the total cost of self-injectable MS drugs. (+info)
The impact of expressions of treatment efficacy and out-of-pocket expenses on patient and physician interest in osteoporosis treatment: implications for pay-for-performance programs.
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BACKGROUND: Clinical practice guidelines (CPGs) are increasingly used as the basis for pay-for-performance (P4P) programs. It is unclear how support for guidelines varies when treatment efficacy is expressed in varying mathematically equivalent ways. OBJECTIVES: To assess: (1) how patient and provider compliance with osteoporosis CPGs varies when pharmacotherapy efficacy is presented as relative risk reduction (RRR) versus absolute risk reduction (ARR) and (2) the impact of increasing out-of-pocket drug expenditures on acceptance of guideline concordant therapy. DESIGN: Cross-sectional survey of patients and physicians. SUBJECTS AND SETTING: Female patients age >50 years and providers drawn from academic and community outpatient clinics. MEASUREMENTS: Patient and provider acceptance of pharmacotherapy when treatment efficacy (reduction in hip fractures) was expressed alternatively in relative terms (35% RRR) versus absolute terms (1% ARR); acceptance of pharmacotherapy as patient drug copayment increased from 0% to 100% of the total drug costs. RESULTS: Compliance with CPGs fell significantly when the expression of treatment benefit was switched from RRR to ARR for both patients (86% vs 57% compliance; P < .001) and physicians (97% vs 56% compliance; P < .001). Increasing drug copayment from 0% to 10% of total drug cost decreased patient compliance with CPGs from 80% to 57% (P < .001) but did not impact physician compliance. With increasing levels of copay, both patient and provider interest in treatment decreased. LIMITATIONS: Respondents may not have fully understood the risks and benefits associated with osteoporosis and its treatment. CONCLUSION: Patient and provider interest in CPG-recommended treatment for osteoporosis is reduced when treatment benefit is expressed as ARR rather than RRR. In addition, minimal increases in drug copayment significantly decreased patient, but not provider, interest in osteoporosis treatment. Designers of P4P programs should consider details including expressions of treatment benefit and patients' out-of-pocket costs when developing measures to assess quality-of-care. (+info)
Effect of cost sharing on screening mammography in Medicare health plans.
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Elimination of co-payment for weight management counseling. Direct final rule.
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The Department of Veterans Affairs (VA) is taking direct action to amend its medical regulations concerning co-payments for inpatient hospital care and outpatient medical care. More specifically, this rule designates weight management counseling (individual and group sessions) as a service that is not subject to co-payment requirements. The intended effect of this direct final rule is to increase participation in weight management counseling by removing the co-payment barrier. This direct final rule also amends the medical regulations by making nonsubstantive changes to correct references to statutory provisions. (+info)