Him ORIGINAL CONTRIBUTION Pharmacy Benefits and the Use of Drugs by the Chronically Ill Dana P. Gold Context Many health plans have instituted more cost sharing to discourage use of GeatreyF Joyce, PAD Imor expensive pharmaceutal and to reduce dug pending Tune] Bearee MD, PHD (Objective To determine how changes in cost sharing affect use of the most com- Irony used deg eases among the privately insued and the coil i Design, Setting, and Participants. Retrospective US study conducted from 1997 £02000 examin nked pharmacy cans data with health plan beni designs from 30 employes and 52 heath pans. Parpants were 528960 private insured ben efcares aged 18 to 68 years and envlled from 1 to 4 year (960791 person-years). Hamels Lantinins PHL DA asin outcome Measure Relative changein drug days supplied (per member, er teven M. Teutsch, MD, MPH year) when co-payments doubled in a prototypical drug benefit plan. Results Doubling co-payment was associated wth eductionsinuse of therapeu- N RECENT YEARS, MANY HEALTH tic classes. The largest decreases occurred for nonsteroidal anti-inflammatory drugs plans have implemented policies to (NSAIDs) (45%) and antihistamines (44%). Reductions in overall days supplied of an- Contain drugs cons inclidingrais- thypetipiemis (34%), anulerans (332), antasthmates 2%), anthhyperten- ingbeneficisry co-payments, nan~ ses 26%), antdepresants (26%), and anidlabelcs (25%) were ako observed. Among dung in ol enercsequring mae ales dagrored ashen contin anrecving ogangce we wale deena ad expanding ace ot _esporsveo co-payment changes Use of antidepressant by depressed patents de- orc services and expancling use of Cjned by 8%, use of anthypertensves by hypertensive patents decreased by 10%. ti i‘ re Larger reductions were observed for arthritis patients taking NSAIDs (279%) and al- fects on total drug spending. For ex- _jergy patients taking antihistamines (31%). Patients with diabetes reduced their use ample, doubling co-payments re- of antidabetes drugs by 23% duced total drug spending by 19% '© Conclusions. The use of medications such as antihistamines and NSAIDs, which are sy ame multiyear study of25 60m taken intermittently to treat symptoms, was sensitive to co-payment changes. Other pantes.! Such large responses often raise medications—antihypertensive, antiasthmatic, antidepressant, antihyperlipidemic, an- cconcetns about adverse health conse- _fiyieerant, and antidiabetic agents-—also demonstrated significant price responsive- «quences, particularly forchronicallyll_ ness. The reducton in ute of medatons for individuals n ongoing care was more individuals, Indeed, lage changes in modest Stl significant increases in co-payments rae cncerm about adverse health dug benefits are sometimes associ. consequences because of the large pice effeds, expecially among dabetic patents Taouri, PRD) 2 MPH, re pePH ated with substantial morbidity and JAMA 2004,291:2344.2350 ‘wen ama.com mortality in certain high-risk popula: tions. pends on a drug's therapeutic class" METHODS In the privately insured nonelderly andthatincreased costsharing mayde- We assembled a dataset of pharmacy population, the paterns may dlfer.AI- crease “nonessential” drug use more and medical clams from 1997 to 2000 though there is also evidence tha this than essential rug use!” This makes poptlation changes ts pattems of drug. identfyingthe therapeutic classes most jar Aflaians RAND Sais Novia, CDS tse when benefits change, there is less sensitive to benefit changes critically Clan inj ar ares er rt Seo fro Meek Wes sont Pi tania and simportant Bees and Cate eather Foon quences. One plausible explanation is We examined how changes in ben- Galan uth thatthe health consequences manifest efit design among privately insured Dra ow with Genentech, Sout Sn Fan over many years,andrelevantlongiti-- populations lfectuse of the mostcom- fetes Me Landen ane dlinal databases are scarce. In addi-- monly used drug clases. In addition, —ojes an stot options hole of Mek. Br tion, there may be diferent responses, we identified populations more likely use on ams tnlsect pts bk depending on the diseases the drugs tobe at risk for adverse health elfects Conon bar: Bane Conan Por eve cs one GeatreyJofe PRD, RAND, 1700 Maint Sata treat, Several studies suggest that con- and solated their responsiveness tocost {ter Joes Fn RAND, 700 Mant Santa sumer sensitivity to cost sharing de- sharing. soycediranaog). evidence of adverse health const 2844, JAMA vy 19,2004 Vol 291, No. 19 Reprinted) (©2004 American Medical Association. AI rights reserved jamanetwork.comy by a University Town Library of Shenzhen User on 03/18/2023PHARMACY BENEFITS AND CHRONICALLY ILL PATIENTS: for 30 large US employers covering ‘Table 1 TerapeutieCasrer Ranked by Spencing, 2000 528069 beneficiaries continuously en- a by Spensings rolled forup to years (n=860701 pes- Theapete Cass =o Son-yeats). The claims captured all RET ao healthcare claims and encounters, in- EESE Bears cluding prescription drugs and inpa- Jegirsoie Ea tent emergency, and ambulatory sct- aa aera TSO ices. Most drug claims included JERSE ear information on the type of drug, drug Antidiabetic agents excuding insulin) Tress a name, national drug code, dosage, days Talcun chamna blockers supplied, and place of purchase (retail Frgatenan-conveting eyiva nore ‘or mail order). The medical claims in- jrBlockew cluded the date of service, diagnosis and Fistmne Fl riage procedure codes, type of facility, and Above 10 sas5=5 BE clinician, lange ro} ‘We merged the clalms data with in- _"Sprara Wasa G80 SSIS RT EO SSSR ARTS formation on the health insurance ben- fits for each covered individual. Most ‘of the companies offered employees a sociate each drug with a therapeutic had at least 1 drug claim, which was choice of health insurance plans, yield- class. TABLE I shows the 10 most com- done separately for each year. We then ing data from 52 health plans (n=102 mon therapeutic classes (in terms of compiled a list of all the drugs pur- plan-years). These plans varied across dollars spent) in our sample for 2000. chased by these beneficiaries and ag- companies and by year because some Together, these 10 classes accounted for _ gregated this list across plans to yield of them changed their benefits struc- more than $152 million in sales across the market basket. To assign prices, we ture during the observation period. Al- all plans in our sample and 51% of all used the average co-payment for each though employees typically had a drug spending. Not surprisingly, the drugineach plan. In this way, our pri choice of medical plans, only 2 com- best-selling drugs include treatments for for a drug reflected not only the way a panies had drug benefits that differed high cholesterol, depression, gastroin- drug was ered butalso these other fac- across the plan options, thereby redue- testinal disorders, joint pain, allergies, tors, such as the accessibility of net- ing potential bias from selection of drug and heart disease ‘work pharmacies, Formally, the index plans according to anticipated use - . is computed as a weighted sum of av- For each plan-year, weobiained cop- Price Index of Plan Generosity cerage co-payments for each drug in the les of the summary benefit design. Sa- Our key independent variable was an market basket, where the weights r lient benefit information was then ab- index of plan generosity. In general, it flect the per-beneliciary numberof pre- stracted by 2 members of the research is dificult to translate the stated phar- scriptions filled for each drug, team. The few instances in which there macy benefit into actual prices that ‘were discrepancies were resolved with consumers face. Mulitier formularies Multivariate Regression 4 third opinion [rom one of the prin- are the standard for most private We modeled the likelihood that bet cipal investigators. Abstracted drug- plans, and they also offer discounts for _eficiaries used any drugs in a therape benefit detalsincluded co-paymentsor purchases through mail-order or _ticclass,as well as their spending, con- coinsurance rates for retail and mail- in-network pharmacies. These added Ungent on having filled at least 1 order pharmacies, generic substitu- complexities mean that the price a prescription in that class. We es lion rules, and a list of drugs or drug consumer will pay for a given drug mated these outcomes by using a 2-patt classes excluded from coverage. Char- depends not only on which ter it is model estimated separately for each acteristics of the medical benefit in- placed in but also on where it is dis- therapeutic class. We used probit re- cluded deductibles and patient cost- _pensed. To address this issue, we con-_ gression to estimate the probability that sharingarrangements forinpatientand structed a price index for the phar- amember had atleast 1 pharmacy claim ambulatory settings. The result was a macy benefit according to cost sharing in the class. The second part of the data sct inking covered beneficiaries’ fora standardized list of drugs model used a generalized linear model druguseand insurance benelitsforap- The index represents the expected to eslimatedrugspending among mem proximately I million person-years. out-of-pocket spendingineach plan for bets who were users. We chose age a standardized “market basket” of eralized linear model with a logarith- Classification of Drugs drugs. The market basket was gencr- mic link function because it predicted We used a common classification ated bydrawinga representativesample dayssupplied better than a 2-part model scheme—the 2000 Red Book—1o as- of 100 enrollees from each plan who with log-linear regression in the se (©200¢ American Medical Association, AI rights reserved. (Reprint) JAMA, My 19,2004 Vol 291, No. 19. 2845 jamanetwork.comy by a University Town Library of Shenzhen User on 03/18/2023PHARMACY BENEFITS AND CHRONIGALLY ILL PATIENTS: variates were binary indicators for age categories, a binary indicator for male sex, median household income in the ZIP code of residence, a binary indica- FRING ETT TBAT — tor for active or retired status, a cat- an Crtonsior gorie variable for urban residence, and Average co parent § binary indicators for years to conto for Pe inetrends, Wealso controlled for co- eS Sa morbid conditions by using a set of di ea a Ee sccoding to Internation ia 0 2i%e Classification of Diseases, Ninth Revi- Farad bands aa som ICD) dagnones (Full model Aoqratredeands a0, sults areavalable from the correspond Fisage pen ite 60, 8 Tee ATO TETRA ing authors.) eee rile Gaaeies For each therapeutic class, we used s5atio9 472,104) 42.0021) 40-0) the Fesus from the 2-part model to ea eo simulate total days supplied. Speci i a a a ily, we used estimates from the first Soon ana pt of the motel to predict the prob- WMedianincomeinZP code aoee5 aa0e0 6406 S820 ability of nonzerodays supplied for each Goats person der iferent vals the = Dabetes payment index. We used the second Sas prt of the model to predict cays sup- Sang pie contingent om having. a least Gastie act disorder claim. Total days supplied were pre- Fpetensen 35 Gicted by using the product ofthe 2 Sepressen The predictions were then averaged Sysco cover all individuals in the sample for age 2 Seger 2 827 cach value ofthe co-payment index. We ae hen eal becire ey geno con nadoany ancy wees Predicted use for index values of 168 ‘Sains (antec ce his becrparenisaterscay wasters and 336, These values correspond to moving from a 2-tier plan with co- payments of $6.31 for generics and cond stage, butour conclusions were in- drugs. Nonsteroidal anti-inflammato- $12.85 for brand drugs to one with co- sensitive to this choice ries included the cyclooxygenase 2 in- payments of $12.62 and $2: ‘Our therapeutic elasses included most hibitors. Antiasthmatics included anti-__ spectively. Although the index value of of the top-selling drugs, as shown in cholinergics,anti-inflammatory asthma 336 was not observed in our sample, 70, re- Table 1. We combined several classes agents, leukotriene modulators, oralste- _ this level corresponds to co-payments used to treat the same chronic disease. roids, steroid inhalers, sympathomimet- observed recently in the marketplace For antihypertensives, we included an- ses, and xanthines, Simulations of a 50% increase (using slotensin-converting tors, calcium channel blockers, diuret- _erosity, we included binary indicators tionately similar results. All costs are ‘me inhibi Inaddition to our index of plan gen- values within sample) yielded propor- les, B-blockers, and angiotensin II identifying plans with coinsurance rates in US dollars. receptorblockers. Antidiabetesdrugsin- and policies requiring mandatory ge- eluded sulfonylureas and other oral erie substitution. The latter have been Chronic Condition Analysis agents stich as metformin and gl- shown to have a large independent Patients were identified as having a fon spending.’ Other indepen- chronic condition if their medical ‘cause injectable drugs often have differ- dent variables in our model included claims included 2 or more office visits cent benefits, Antiulcerants included H, a set of variables to describe the medi- with the corresponding ICD-9 code receptor antagonists and proton pump cal benefits: deductibles, co-pay- (available on request) and they filled at Inhibitors, as well as other gastroint Lunal drugs not elsewhere classified. An- cian ollie visttsand a binary indicator peutic class, The chronic population itazones, Insulin was not included be- _effe ‘ments, oF coinsurance rates for physi- least | prescription forthe listed thers Lidepressants included selective seroto- to identify plans with coinsurance rates varied by therapeutic class: depres- nin reuptake inhibitor and tricyclic forphysician office visits, The other co- sion (for antidepressants), hyperten- 2846. JAMA sy 19,2004 Vol 291, No. 19 Reprinted) (©2004 American Medical Association. AI rights reserved jamanetwork.comy by a University Town Library of Shenzhen User on 03/18/2023PHARMACY BENEFITS AND CHRONICALLY ILL PATIENTS: sion (antihypertensives), hypercholes- terolemia (antihyperlipidemics), gastric acid disorder (antiuleerants), asthma ‘Table 3. Unadjusted Per Member Antal Days Supple for Various Drug Clases” Days Su ‘orPatenif Hi =1 Daye supped (antiasthmatis), diabetes (antdiabet- Preserpton for Al Patents tes), arthritis (nonsteroidal anti- 6 = inflammatory drugs [NSAIDs)),andal- AGE nhibios 2 lergicrhinitis (antihistamines). Patients Boles zr with multiple conditions were in Can carnal bodars n cluded in each relevant subgroup (eg, Durses = patients with dishetes and hyperten- _ Argel Trecsplr Basta e Sion were included in the diabetes and Nonstroda ant-anmatons 7 hypertension analyses). Por each sub- PoWstanes a group, weestimated 2 models: Hor dis- icepressars ease-specific drug use and Lfor use of | Saiypetceries 2 allother drugs. Asan example, for in- iewars 3 dividuals who had hypertension and Obst relies PP 7 a met the criteria above, we estimated otasthmatis S 10 their use of antihypertensives and all *vidabeties a 7 other nonhypertensive medications. We ‘Sufonylureas 8 " er kes TY z then predicted use for each group and tach orcasure by following the beth. SECIS ACE ores anic grams ROR RRE ER cos outlined above: fo Arent tus nate artes The RAND Human Subjects Prote ee ion Committee ruled that this re~ [apres setsaihmes NY Snmeanens tore ments search was exempt from institutional review board approval. $136, and aninterquartle range of$120 _ used most heavily, reflecting the chronic RESULTS to $184 at the plan level (n= 102). nature of these conditions and their TABLE 2 shows the characteristics ofthe Within plan type, I-ter plans were the treatment. In contrast, NSAIDs (7+ plans in our study sample. We broadly most generous (index value of $124), days), antihistamines (90 days), andan- classified our plans into 1-tiet followed by 2-tier plans ($168), 3-tier _tiasthmaties (117 days) were not used Stier, or coinsurance plans, with be- plans ($179), and then coinsurance continuously throughout the year by ween 142217 and 343117 person- ($181). The demographic characteris- most patients. These findings suggest a years for each type. The I-tierplansare tes of patients enrolled in each plan classification of medications into 3 broad, the most generous; these plans re-type differed; for example, men made groups: drugs that forestall disease quire on average a $6.05 payment per up 61% of the sample—not surpris- progression and avoid long-term com- retail prescription for a 30-day sup- ing, given that this wasa sample of pri- plications (antidiabeties, anuihyperte ply. Co-payments are higher on mail- mary beneficiaries—but the propor- sives, and antihyperlipidemics), medi- coder prescriptions (averaging $9.60 per _ tion varied considerably by plan type. cations that largely treat symptoms or prescription), but theyallow up 10a 90- These differences underscore the im- intermittent conditions (NSAIDS and day supply. Average retail co- portance of our multivariate ap- antihistamines), and drugs with char- payments in a 2-tle plan are $6.31 for proach. On the other hand, the preva- acteristics of both (antidepressants, an- 2 generic drugs and $12.85 for brand lence of chronic disease was fairly iulcerants, and antiasthmatis). drugs. Average co-payments ina 3-tier similar across plan types, which sug- ‘The FIGURE shows the predicted ef- plan range from $5.70 10$20.81.Mail- gests that unobserved health differ- fects of doubling co-payments in each order co-payments for 2-tierand 3-tier ences were probably minimal. therapeutic class for the entire sample plans range from $8.91 for genericsin TABLE 3 shows annual drug use in and a subset of patients receiving on- a 3-tier plan to $33.02 for nonpre- each therapeuticclass. On the whole,an- going treatment for a chronic illness. ferred brands, hypertensives were used most fre- We predicted the percentage change in The relative generosity ofthe plan is quently (22% of the population). annual days supplied in response to a conveyed by the average price index, NSAIDs (10%), antihistamines (17%), _ doubling of co-payments after adjust- which reflects average patient out-of- antidepressants (12%), and antihyper- ing for demographic and health char- pocket spending for our market bas-_lipidemies (11%) were also used fre- acteristics. The change was computed kket of drugs. Ourgenerosity index had quently. Antidiabetes drugs (390 days) _by predicting use for a drug plan with an overall mean of $150, a median of and antihypertensives (386 days) were an index value of 336, with predicted (©200¢ American Medical Association, AI rights reserved. (Reprint) JAMA, My 19, 2004Vol 291, No. 19. 2847 jamanetwrork.com/ by a University Town Library of Shenzhen User on 03/18/2023PHARMACY BENEFITS AND CHRONIGALLY ILL PATIENTS: Figure, Predicted Change i Antual Das Supplied When Co-payiments Double by Drug Class ahd Populauon “Thepecentage change in per member annual ays supped hen copayments eat by OOH nthe average? er planisshown, Tip asreal co paymenis of $63 for genes and S12 85 for brand-name drugs and hasan index vale of 168. Fo each croicaty subpopulation, we estimated the Cange nr ise thin cls eg use of atcepresans by depressed patients) and aus of das eg use lobe medeaos by depresed patient) when co-payment cease by 100% NSAiDendestes nostril namo drugs ee livisls with diagnosed hyperten- ceptor antagonists and proton pump on Co-payments bre Doubled for c lone exce ts inhibitors). We found that a doubliny ih rected change fy Medeston sion, The lone exception was patients inhibitors). We found that a doubling U: (Chroneatly Patentes with diabetes: their response wo adou- of co-payments led to a 32% reduc- — ——arargenaye ling of co-payments (23%) was virtu- tion in their use. Use of medications ication ‘Supptiod, ally identical to that of the overall pop- without close OTC substitutes— OTC aubsttates lation (25%) defined as antidiabeties, antiasthm: ‘Cote subst The Figure also compares use within ies, antihyperlipidemics, antibypert class and outside class for chronically sives, and antidepressants—decreased, ill patients only. Use of antidepres- by only 15%. In contrast, we saw only sants by depressed patients declined by modest differences by drug type (21% 8% when co-payments doubled; how- for brand name vs 16% for generic) ever, their use of all other drugs de- Taken together, the results suggest that clined by 25%. Use of antihyperten- patients are more likely to forgo higher- sives by patients with high blood priced medications and substitute less- pressure declined by 10%, whereas their expensive OTC medications when pos- use ofall other drugs decreased by 27%. sible as their out-of-pocket burden use for a plan with an index value of Similar but less dramatic differences increases. 168, which corresponds to the effect of emerged for antihyperlipidemics, an- co-payments in a 2-tier plan increas-uleerants, and antiasthmatics, Poran- COMMENT ing from $6.31 for generics and $12.85 _tihistamines and NSAIDs, the pattern In previous work, we found consider- for brand drugs to $12.62 and $25.70, reversed. Patients with arthritisandal- able price sensitivity in the demand for respectively. For the entire study _lergic rhinitis reduced their disea sample, we observed substantial redue- specific use by 27% and 31%, respec- age population with employe: Lionsin spending forall classes ofdrugs. tively, whereas their use ofother drugs provided insurance.' In that study, dou- The largest decreases occurred for actually declined by only 22%. bling co-payments in a 2-tiered plan NSAIDs (45%) and antihistamines One might expect to see more price reduced overall drug spending by one (44%). Butthe most striking feature is responsiveness for drugs with close third, but itis unclear which therapet the much lower responsivenessamong over-the-counter (OTC) substitutes or tic classes were most affected. The re- chronically ill patients. For example, for high use of antidepressants by depressed pa-_ presents the predicted change in an- doubling co-payments ina typical 2. tients declined by only 8% when co- nual days supplied when co-payments plan is associated with significant re payments doubled compared with 26% are doubled for people with 1 of 8 ductions in use across 8 of the most overall, Use of antihypertensives wasre- chronic conditions. Medications with widely preseribed therapeutic classes. prescription drugs among a working- priced medications, TABLE4 sults presented here demonstrate that duced by 26% for the entire popula- OTC substitutes included NSAIDs,an- The largest reductions were for drugs tion compared with only 10% among tihistamines, and antiulcerants (H, re- with close OTC substitutes that pri- 2848 JAMA say 19,2004 Vol 291, No. 19 Reprinted) (©2004 American Medical Association. AI rights reserved jamanetwork.comy by a University Town Library of Shenzhen User on 03/18/2023marily treat symptoms rather than the underlying disease. Doubling co- payments was associated with r duced annual days’ supply of antihis- lamines and NSAIDs of about 45%; by comparison, use of antihypertensives and antidepressants decreased by 26%. Patients do not respond indiscrimi- nately to co-payment increases. Indi- viduals receiving treatment for a sp cific condition are less likely to reduice their use of disease-specific medica lions, Por example, patients with diag- nosed high blood pressure reduced use of other drugs by 27% when co- payments doubled but only by 10% for their antihypertensive medication (Fig- ure). Because the average patient with hhigh blood pressure uses 386 days of antihypertensive medications annu- ally (Table 3), these estimates imply that «4 doubling of co-payments would re- duce days supplied by more than 1 month (38.6 days). This pattern—less responsiveness 10 price changes for disease-specific medi cations relative toall other medications— was found in 5 of the 8 therapeutic classes we studied (antidepressants, an- hypertensives, anthyperlipidemics, an- tiulcerants, and antiasthmaties). Use of antihistamines and NSAIDs by people with allergie rhinitis and arthritis, r spectively, operated in the opposite di- rection, meaning that these patients were price sensitive when taking their disease specific medications. Patients diag- nosed with diabetes were a notable ex ception; use of antidiabetes medications and nondiabetes medications de- creased by about one quarter in re- sponse to a 100% increase in co- payments. According to Table 3, annual days supplied decreased by more than 3 months when co-payments doubled (rom 390 to 293 days). In supplemen- tal analyses, we found that use of inst lin, which we purposely excluded from the antidiabetes class because it soften, covered differently by plans, was less sponsive to benefit changes, with use de- creasing by only 8% when co-payments doubled The populations most sensitive 1o price changes were the patients taking (©2004 American Medical Association, All rights reserved, PHARMACY BENEFITS AND CHRONICALLY ILL PATIENTS: long-term medications but who were not receiving ongoing eae for the con- dition (atleast 2 medical visits per year for that condition). More research is needed to determine whether this price- sensitive population consists of people atrisk fora disease or for whom the dis- case is well controlled and who do not seck regular care or people with ad- vanced disease who are not being weated appropriately. Some ofthis price sensitivily may be beneficial for soci- ety in the sense that it reduces excess consumption of drugs whose costs are greater than the (monetized) health benefit. On the other hand, recent evidence suggests that there may be substantial therapeutic benefits of low- ering blood pressure and serum cho- lesterol level forall individuals at risk, not sitnply those with elevated rates."" A recent clinical tial also demon- strated that metformin can prevent or delay the onset of type 2 diabetes in pa tients at risk (although not as well as diet and exercise). ‘When we examined the chronically All popullation receiving routine eare, a group of patients who are most likely to benefit from drug treatment, we still found that doubling co-payments isas- sociated with reductions in drug use of 8% to 23%, Although lower use of an- Uubistamines oF anti-inflammatories is unlikely to affect patients’ underlying health conditions, significant reduc- dons in the use of antidiabetic agents oF medications to treat dyslipidemia may have short- and long-term clini- cal consequences, ‘Our findings raise concern that co- payment increases could lead to ad- verse health consequences, a least for individuals with some conditions. In cour sample, we found evidence that co- payment increases led to increased use of emergency department visits and hospital days for the sentinel condi- tions of diabetes, asthma, and gastric acid disorder: predicted annual emer- gency department visits increased by 17%and hospital days by 10% when co- payments doubled (data not shown). However, because of limited informa- tion about the full extent of medical benefit coverage and the choice of medi- cal plans (which are self-selected ina way that the drug benefits are not), these results are not definitive. Other studies have found mixed evidence on this issue? There are several other limitations, First, our sample was drawn froman sured working-age population, and thus ‘our results are not necessarily general- izable to other populations stich as the poor or the elderly. Second, we identi- lied chronically il patents from claims data. The main concern with this ap- proach is false positives if rule-out di- agnoses are recorded on the claims. We tried to minimize this error by restrict- ing our analysis to users of di specific drugs, requiring multiple phy sician visits or hospitalizations for the condition and excluding laboratory claims from our diagnosis counts. Fi- nally, in all but 2 of our companies, ben- cliciares did not have a choice of drug benefits; most companies offered the same drug package oall employees even ‘as medical benefits varied. Excluding these companies from our analyses did not appreciably alfect the results, ‘CONCLUSION Rapid changes in drug benefits have shifted alarger burden of pharmacy costs ‘onto beneficiaries. Beneficiaries have responded by reducingtheiruse ofdrugs, but their responsiveness varies substan Ually among the top-selling therape licelasses. The use of medications such 4s antihistamines and NSAIDs that are taken intermittently to treat symptoms issensitivetoco-payment changes. Other medications—antihypertensive, anti- asthmatic, antidepressant, antibyperlip- idemic, antiulcerant, and antidiabetic agents —also demonstrate significant price responsiveness. However, when ‘one restricts attention tosubgroups with identifiable chronic illness, the reduc lion in use of medications for those con ditions is more modest. Sull, signifl- ceant increases in co-payments do raise concern about adverse health conse- quences because ofthe large price elfects, especially among diabetic patients. (Reprint JAMA, My 19,2004 Vol 291, No. 19. 2849PHARMACY BENEFITS AND CHRONIGALLY ILL PATIENTS: ‘Author Cnbibuions: DrGolaranhadtulaccesstofllecual content: Goldman, Joye, scarce, Pace, from Merck and Co andthe Agency for Heat ‘lot the tain tne study and takes sponta fr Selomen,Lacur, Landsman, Teutch Research and Quay f rs Calman ar Joye ‘heintegntyofthedsts andthe acuayofthedsta Seta) expartiee: Cadman, Joye, Exace,Lands- Roe ofthe Sponsor: RAND iss responsi ls man Tesch forthe arels content. Te Ageney for Healthcare ‘Study concept and dein: Gelman, Joyce Excarce, ained funding: Colénan, Joyce Sloman, Laour, Research and Gutsy, Calor Heats Foun Seeman, Laut Landsman, Teach tandsman,Teutch Aiton, and Marck and Co did nt nave ay uta. ‘equa afd: Caldman. yee, Solomon Laoui, Admnisttve tenia armateasupport Joyce, ty over the dengn and conduct ofthe study ‘naiyesandinteypretaton faut: Cogan, Joyce, Ecc, Pace te collection, analysis, preparation, and intr ace Pace, Solomon, Landsman Teutch, Superson: Colman, Joyce, Tech Dretaton of the dat! or preparation f the manu Dratting of the manusenpt: Goleman, Joyce, Fundng/Support: Osa were provided by Ingenix ser ings, Tete Ine The resereh was sported by the Calforia Acknowledgment: We received thought sugges Citeal revision ofthe manuscript for mpotatin- Healthcare Foundation, wth additonal funding Sone fam Mare Berger, RNS 4. Jyee GF, scarce I, Solomon MD, Godman DP. 6. Federnan AD, Mans AS,Ross-DegnanD,Soume- 1. Law MR, Wl Rifts thresholds: ther Enpoye dug beef uns and spending on prea 6, Afni 2 Supplemeral surance and use exstence under serliny. Bi! 2002;324 1570: septn ug sata, S00 as 1723-1799, sleeve cionicardugsamongeaeh ede 376 2 nen Ward NB, shapro ME, calegoC. Vaghai- te benetisanes withcoronryheartdsese JANA. 12. Knowr WC, Baret-Connor Fowet SE. wala R, Brook RH. Termination of Medial ben- 2001 286:1752-179, {orth Diets Peventon Progra Research Group. 1 Tolow-apsudy one year later Eng!) Med. 7, uskanp HA, Deverka PA. stein AM, Epstein Reguchonnfeinedence of ype? cabels wi le Sees zee et Rs, McGuigan KA, Frank RG. The effec of stleinervertion or melon Ng! Med 2002 2 Tarbiyn , LapreeR Haley J, et a Adverse Incenive-bated formulas on preserption-dryg 346393-403, vents associated with preseription drug cost- ulation and spending N gl! Med 2005;349 13. ScheeweissS, Waker AM, Cyn R, Madu ‘Sharng among poorandelety pos JAMA 2001, 2224-2252 IM: OormathC, Sourmera $8. 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Med Care. 2003; Inui. 196522 396-403, ‘alconomes Co, 200, Soastoe The most exciting phrase to hear in science, the one that heralds new discoveries, is not “Eureka!” (found 1) but “Thats funny...” “—saac Asimoy (1920-1992) 22850. JAMA by 19,2004 Vol 291, No. 19 (Reprinted) (©2004 American Medical Association. AI rights reserved ‘Downloaded From: https:/jamanetwork.com/ by a University Town Library of Shenzhen User on 03/18/2023