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Elderly People and Welfare Recipients Had More Adverse Events and Less Use of Essential Drugs After Prescription Cost-Sharing Was Implemented
January 24, 2001 — Increased cost-sharing for prescription drugs in the Canadian province of Quebec was followed by reductions in the use of essential drugs and a higher rate of serious adverse events and emergency department visits by elderly people and welfare recipients, according to an article in the January 24/31, 2001 issue of The Journal of the American Medical Association.
Robyn Tamblyn, Ph.D., and colleagues at McGill University, Montreal, Quebec, analyzed data on 93,950 elderly people and 55,333 adult welfare recipients before and after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996. The purpose of the study was to determine the impact of prescription cost-sharing on use of essential and less essential drugs, and rates of emergency department (ED) visits and serious adverse events associated with reductions in drug use before and after policy implementation.
According to background information cited in the study, cost-sharing is intended to deter the use of drug therapies that do little to improve health. But cost-effectiveness rests on the assumption that people will be able to pay for essential drugs and that they will make rational choices about which drugs to use and abandon. Otherwise, the use of essential drugs will be curtailed to control drug expenditures, and short-term savings in the drug budget may be offset by downstream costs to treat potentially preventable illnesses.
In 1996, Quebec attempted to enhance equity of access to prescription drugs by legislating mandatory drug insurance for all residents. To help pay for this coverage, an annual deductible and a 25 percent coinsurance charge was instituted for previously insured beneficiaries who received free medication: elderly people and welfare recipients. The authors analyzed data from 32 months before and 17 months after introduction of the policy, using databases that keep track of beneficiary demographics, prescription and physician claims, and hospitalizations.
Essential drugs were defined as "medications that prevent deterioration in health or prolong life and would not likely be prescribed in the absence of a definitive diagnosis" and included such drugs as insulin, antihypertensive agents, thyroid medication and anti-seizure drugs.
"After cost-sharing was introduced, use of essential drugs decreased by 9.12 percent in elderly persons and by 14.42 percent in welfare recipients; use of less essential drugs decreased by 15.14 percent and 22.39 percent respectively," they report.
As expected, there was a significantly higher rate of adverse events and emergency department visits among individuals who reduced their use of essential drugs, compared to those who did not. "The rate (per 10,000 person-months) of serious adverse events associated with reductions in use of essential drugs increased from 5.8 in the prepolicy control cohort to 12.6 in the postpolicy cohort in elderly persons (a net increase of 6.8) and from 14.7 to 27.6 in welfare recipients (a net increase of 12.9)," the authors write.
"Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 per 10,000 person-months in elderly persons (prepolicy control cohort, 32.9; postpolicy cohort, 47.1) and by 54.2 among welfare recipients (prepolicy control cohort, 69.6; postpolicy cohort, 123.8)," they continue. "These increases were primarily due to an increase in the proportion of recipients who reduced their use of essential drugs."
Reductions in the use of less essential drugs were not associated with an increase in risk of adverse events or emergency department visits.
The authors suggest consumers may not have the information they need to make wise decisions about necessary treatment. "We estimate that for elderly persons alone, the drug policy reform in Quebec may result in 7,000 additional adverse events per million annually," they write.
"In light of the substantial impact that drug policy can have on the population's health, there is a need to redress the relative scarcity of scientific data on the outcomes of policy interventions. Our results suggest that more stringent cost-sharing pharmaceutical cost containment policies in other parts of Canada and the United States may contribute to avoidable illnesses," they conclude.