Health Care Costs and Financing

Older patients stop using inhalers and end up in the hospital when insurers enact deductibles and copayments

Insurers have tried out many methods for reducing their drug benefit costs, including having patients share costs through copayments and deductibles. These methods may save the insurer money on drug expenses, but they can also produce the unintended consequence of patients foregoing their medications and ending up in the hospital, according to a new study.

The researchers studied how changes in drug benefit policies affected emergency hospitalizations of older patients in British Columbia who used inhaled medications to treat their respiratory conditions. The insurer first offered adults 65 and older full coverage for prescription medications. Later, the plan charged fixed copayments of $10 to $25 for medications. Finally the plan switched to an income-based deductible (IBD) plus age-based copayments for prescription medications.

Many patients stopped using their inhalers to control their chronic obstructive pulmonary disease when they encountered fixed copayments and IBD, but the decrease was greater with IBD. The greater decrease under IBD was associated with increased visits to physicians and a surge in patient hospitalizations for chronic obstructive pulmonary disease, asthma, and emphysema (CAE). The authors suggest that instituting deductibles may have prompted patients to forego their inhalers because they were struggling to pay for their medicines until they reached the deductible threshold. Patients may have increased their visits to physicians in hopes of receiving free drug samples or prescriptions for less expensive medications.

As solutions, the authors recommend that drug plans offer continuous coverage of one or more drugs per patient to prevent them from discontinuing their medicines. They also recommend that plans permit patients to pay deductibles in installments to ensure they have coverage throughout the year. This study was funded in part by the Agency for Healthcare Research and Quality (HS10881).

See "Emergency hospital admissions after income-based deductibles and prescription copayments in older users of inhaled medications," by Colin R. Dormuth, M.A., Sc.D., Malcolm Maclure, Sc.D., Robert J. Glynn, Ph.D., Sc.D., and others in the 2008 Clinical Therapeutics, 30, pp. 1038-1050.

Editor's Note: Also see "Impact of two sequential drug cost-sharing policies on the use of inhaled medications in older patients with chronic obstructive pulmonary disease," by Colin R. Dormuth, M.A., Sc.D., Robert J. Glynn, Ph.D., Sc.D., Malcolm Maclure, Sc.D., and others in the 2006 Clinical Therapeutics, 28, pp. 964-978. A short summary of this article appears in the July 2007 issue of Research Activities, pp. 18-19 (http://www.ahrq.gov/research/jul07/0707RA21.htm).

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