Assessing the Effect of Taiwan’s Outpatient Prescription Drug Copayment Policy in the Elderly Adverse events associated with prescription drug cost-sharing among poor and elderly persons. A randomized controlled trial of co-payment elimination: the CHORD trial. The demand for prescription drugs as a function of cost-sharing. Cost Effectiveness of Two Interventions for Reducing Outpatient Prescribing Costs Association Between Medicare Accountable Care Organization Implementation and Spending Among Clinically Vulnerable Beneficiaries. Changes in drug utilization following the outpatient prescription drug cost-sharing program--evidence from Taiwan's elderly. The medical office of the 21st century (MOXXI): effectiveness of computerized decision-making support in reducing inappropriate prescribing in primary care. Cost-sharing for emergency care and unfavorable clinical events: findings from the safety and financial ramifications of ED copayments study. Impact of the Chronic Care Model on medication adherence when patients perceive cost as a barrier. A Quantitative Evaluation of Medication Histories and Reconciliation by Discipline A prospective trial of a clinical pharmacy intervention in a primary care practice in a capitated payment system. Economic and Policy Analysis of University-based Drug “Detailing The effect of computer reminders on GPs' prescribing behaviour: A cluster-randomised trial Pay-for-performance remuneration for pharmacist prescribers’ management of hypertension Impact of a comprehensive pharmacist medication-therapy management service Addition of generic medication vouchers to a pharmacist academic detailing program: effects on the generic dispensing ratio in a physician-hospital organization.
Objectives . This study uses variance cost analysis and regression analysis as tools for investigating the initial effects of Taiwan ’s outpatient prescription drug copayment program in the elderly . Under its new National Health Insurance program , Taiwan implemented a  prescription drug cost-sharing program  August 1 , 1999 . We compare an elderly population ’s prescription drug use after the policy  was implemented with an elderly population ’s prescription drug use before the policy change to describe initial and general consequences of the drug cost-sharing program . Methods . Approximately 240,000 patients aged 65 and over representing 1,600,000 outpatient prescriptions were drawn from 21 hospitals in the Taipei area for the study using a stratified r and om sampling method . Variance analysis , as used primarily in accounting , was applied to decompose overall cost variance of the policy into the sum of variances of several specific factors that are important to policymakers . The cost variances of each specific factor can be further decomposed into sublevels of analyses . Regression analysis is then applied to better underst and covariates that might influence drug cost variances of significant magnitude . Results . The initial effects of the policy change did not reverse the trend of drug cost increases . Instead , there was a significant increase in total prescription drug costs in the cost-sharing group ( approximately 12.86 % ) and an even higher increase rate in the non-cost-sharing group ( approximately 51.42 % ) . The main reason for the drug cost increase for the cost-sharing group was attributed to an increase in average drug costs per prescription ( explaining 69.20 % of the variance ) . We found physicians seemed to prescribe more expensive drugs and extend prescription duration , especially when drug costs exceed the upper bound of the cost-sharing schedule . By contrast , the main factor contributing to the increase in drug costs for the non-cost-sharing group was an increase in average prescription duration ( explaining 64.98 % of the variance ) . The increase mainly results from the effect of extended prescriptions for chronic diseases that were design ed to reduce unnecessary visits for refills . Discussion . The significant increase in average drug price per prescription indicates that many prescriptions could move above the upper bound of the cost-sharing schedule . The results suggest that the Bureau of National Health Insurance should increase the upper bound . We do not think these effects are unique to Taiwan . Rather , these effects should be considered as countries change their outpatient drug benefit programs . We also found a decrease in utilization of essential drugs with an increase in utilization of nonessential drugs for patients subject to copayments . The results suggest potential adverse effects on patients ’ health outcome CONTEXT Rising costs of medications and inequities in access have sparked calls for drug policy reform in the United States and Canada . Control of drug expenditures by prescription cost-sharing for elderly persons and poor persons is a contentious issue because little is known about the health impact in these subgroups . OBJECTIVES To determine ( 1 ) the impact of introducing prescription drug cost-sharing on use of essential and less essential drugs among elderly persons and welfare recipients and ( 2 ) rates of emergency department ( ED ) visits and serious adverse events associated with reductions in drug use before and after policy implementation . DESIGN AND SETTING Interrupted time-series analysis of data from 32 months before and 17 months after introduction of a prescription coinsurance and deductible cost-sharing policy in Quebec in 1996 . Separate 10-month prepolicy control and postpolicy cohort studies were conducted to estimate the impact of the drug reform on adverse events . PARTICIPANTS A r and om sample of 93 950 elderly persons and 55 333 adult welfare medication recipients . MAIN OUTCOME MEASURES Mean daily number of essential and less essential drugs used per month , ED visits , and serious adverse events ( hospitalization , nursing home admission , and mortality ) before and after policy introduction . RESULTS After cost-sharing was introduced , use of essential drugs decreased by 9.12 % ( 95 % confidence interval [ CI ] , 8.7%-9.6 % ) in elderly persons and by 14.42 % ( 95 % CI , 13.3%-15.6 % ) in welfare recipients ; use of less essential drugs decreased by 15.14 % ( 95 % CI , 14.4%-15.9 % ) and 22.39 % ( 95 % CI , 20.9%-23.9 % ) , respectively . 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 [ 95 % CI , 5.6 - 8.0 ] ) and from 14.7 to 27.6 in welfare recipients ( a net increase of 12.9 [ 95 % CI , 10.2 - 15.5 ] ) . Emergency department visit rates related to reductions in the use of essential drugs also increased by 14.2 ( 95 % CI , 8.5 - 19.9 ) per 10 000 person-months in elderly persons ( prepolicy control cohort , 32.9 ; postpolicy cohort , 47.1 ) and by 54.2 ( 95 % CI , 33.5 - 74.8 ) among welfare recipients ( prepolicy control cohort , 69.6 ; postpolicy cohort , 123.8 ) . 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 ED visits . CONCLUSIONS In our study , increased cost-sharing for prescription drugs in elderly persons and welfare recipients was followed by reductions in use of essential drugs and a higher rate of serious adverse events and ED visits associated with these reductions OBJECTIVES Efforts to improve adherence by reducing co-payments through value-based insurance design are become more prevalent despite limited evidence of improved health outcomes . The objective of this study was to determine whether eliminating patient co-payments for blood pressure medications improves blood pressure control . STUDY DESIGN R and omized controlled trial . METHODS The Collaboration to Reduce Disparities in Hypertension ( CHORD ) was a r and omized controlled trial with 12 months ' follow-up conducted among patients from the Philadelphia and Pittsburgh Veterans Administration Medical Centers . We enrolled 479 patients with poorly controlled systolic blood pressure . Participants were r and omly assigned to : a ) receive reductions in co-payments from $ 8 to $ 0 per medication per month for each antihypertensive prescription filled , b ) a computerized behavioral intervention ( CBI ) , c ) both co-pay reduction and CBI , or d ) usual care . Our main outcome measure was change in systolic blood pressure from enrollment to 12 months post enrollment . We also measured adherence using the medication possession ratio in a subset of participants . RESULTS There were no significant interactions between the co-payment interventions and the CBI interventions . There was no relative difference in the change in medication possession ratio between baseline and 12 months ( 0.05 % and -0.90 % in control and incentive groups , respectively ; P = .74 ) or in continuous medication gaps of 30 , 60 , or 90 days . Blood pressure decreased among all participants , but to a similar degree between the financial incentive and control groups . Systolic pressure within the incentive group dropped 13.2 mm Hg versus 15.2 mm Hg for the control group ( difference = 2.0 ; 95 % CI , -2.3 to 6.3 ; P = .36 ) . The proportion of patients with blood pressure under control at 12 months was 29.5 % in the incentive group versus 33.9 in the control group ( odds ratio , 0.8 ; 95 % CI , 0.5 - 1.3 ; P = .36 ) . CONCLUSIONS Among patients with poorly controlled blood pressure , financial incentives-as implemented in this trial-that reduced patient cost sharing for blood pressure medications did not improve medication adherence or blood pressure control This paper estimates how cost-sharing affects the use of prescription drugs . The data for this analysis are derived from the R and Health Insurance Experiment ( HIE ) , a r and omized controlled trial that r and omly assigned participants to insurance plans with varying coinsurance rates and deductibles . Therefore , the cost-sharing they faced was independent of their health and demographic characteristics . The paper used HIE data from four sites to estimate how drug expenditures vary by insurance plan , and to compare the plan response for drugs with that for all ambulatory expenses . The findings show that : ( 1 ) individuals with more generous insurance buy more prescription drugs ; ( 2 ) the cost-sharing response for drugs is similar to the response for all ambulatory medical services ; ( 3 ) the Dayton , Ohio site had significantly greater drug expenditures per capita than the other sites studied and a significantly higher proportion of drugs sold by physicians ; and ( 4 ) the proportion of br and -name drugs among all drugs purchased in pharmacies was not a function of insurance plan . In the Dayton , Ohio site , a significantly higher proportion of the drugs purchased in pharmacies were br and -name rather than generic This prospect i ve , r and omized , controlled trial , based in a Veterans Administration Hospital general medicine clinic , compared the cost effectiveness of two behaviorally oriented interventions design ed to reduce physicians ' drug prescribing costs . Clinical pharmacists visited one group of 11 physicians during weekly clinic sessions to counterdetail the prescribing of certain targeted drugs . A second group of 10 physicians were given data each week comparing their individual prescribing costs to those of their colleagues ( peer-comparison feedback ) . A control group of 10 physicians received neither intervention . Written patient-specific suggestions for cost-effective prescribing  were employed in both intervention groups . Baseline prescribing costs were monitored through the hospital 's computer during a three-month , preintervention period and a seven-month intervention period . The 2026 written suggestions made by the doctors of pharmacy result ed in 613 ( 30.3 percent ) prescribing changes , including deletion , substitution , or change in dosage of targeted drugs . There were no intergroup differences in the response to written suggestions . However , the group receiving face-to-face visits from the clinical pharmacists achieved lower average prescription costs than the control group during seven of eight months . Intergroup differences were statistically significant ( p < 0.05 ) during three of the last five months of the study . The face-to-face meeting intervention was cost-effective , saving $ 478 per physician over seven months after accounting for Pharm . D. salary costs . There was no significant decrease in the number of prescriptions written by the face-to-face group compared with the control group , suggesting that drug substitution rather than deletion was the method used by physicians to lower drug costs . No savings result ed from the use of peer-comparison feedback . We conclude that personal visits by a Pharm . D. are a cost-effective technique for reducing  physicians ' prescribing costs , and are superior to peer-comparison feedback IMPORTANCE Accountable care contracts hold physician groups financially responsible for the quality and cost of health care delivered to patients . Focusing on clinical ly vulnerable patients , those with serious conditions who are responsible for the greatest proportion of spending , may result in the largest effects on both patient outcomes and financial rewards for participating physician groups . OBJECTIVE To estimate the effect of Medicare accountable care organization ( ACO ) contracts on spending and high-cost institutional use for all Medicare beneficiaries and for clinical ly vulnerable beneficiaries . DESIGN , SETTING , AND PARTICIPANTS For this cohort study , 2 study population s were defined : the overall Medicare population and the clinical ly vulnerable subgroup of Medicare beneficiaries . The overall Medicare population was based on a r and om 40 % sample drawn from continuously enrolled fee-for-service beneficiaries with at least 1 evaluation and management visit in a calendar year . The clinical ly vulnerable study population included all Medicare beneficiaries 66 years or older who had at least 3 Hierarchical Condition Categories ( HCCs ) . Beneficiaries entered the cohort during the quarter between January 2009 to December 2011 when they first had at least 3 HCCs and remained in the cohort until death . Cohort entry was restricted to the preperiod to account for potential changes in coding practice s after ACO implementation . Difference-in-difference estimations were used to compare changes in health care outcomes for Medicare beneficiaries attributed to physicians in ACOs with those attributed to non-ACO physicians from January 2009 to December 2013 . EXPOSURES Medicare ACOs beginning contracts in January 2012 , April 2012 , July 2012 , and January 2013 through the Pioneer and Medicare Shared Savings Programs . MAIN OUTCOMES AND MEASURES Total spending per beneficiary-quarter , spending categories , use of hospitals and emergency departments , ambulatory care sensitive admissions , and 30-day readmissions . RESULTS Total spending decreased by $ 34 ( 95 % CI , -$52 to -$15 ) per beneficiary-quarter after ACO contract implementation across the overall Medicare population ( n = 15 592 600 ) and decreased $ 114 in clinical ly vulnerable patients ( n = 8 673 823 ) ( 95 % CI , -$178 to -$50 ) . In the overall Medicare cohort , hospitalizations and emergency department visits decreased by 1.3 and 3.0 events per 1000 beneficiaries per quarter , respectively ( 95 % CIs : -2.1 to -0.4 and -4.8 to -1.3 ) , and hospitalizations and emergency department visits decreased in the clinical ly vulnerable cohort by 2.9 and 4.1 events per 1000 beneficiaries per quarter , respectively ( 95 % CIs : -5.2 to -0.7 and -7.1 to -1.2 ) . Changes in total spending associated with ACOs did not vary by clinical condition of beneficiaries . CONCLUSIONS AND RELEVANCE Medicare ACO programs are associated with modest reductions in spending and use of hospitals and emergency departments . Savings were realized through reductions in use of institutional setting s in clinical ly vulnerable patients This paper examines changes in drug utilization following Taiwan 's newly implemented National Health Insurance ( NHI ) outpatient prescription drug cost-sharing program for persons over 65 years old . The study is a hospital outpatient prescription level analysis that adopts a pretest-posttest control group experiment design . Selected measures of outpatient prescription drug utilization are examined for cost-sharing and non cost-sharing groups in cost-sharing periods and pre cost-sharing periods . Additional analyses were conducted comparing older patients with and without chronic diseases and differences for essential and non-essential drugs . Patients over age 65 were drawn from 21 hospitals in the Taipei area using a stratified r and om sampling method . This paper yields several interesting findings . First , average prescription cost and prescription period increased for both the cost-sharing and non cost-sharing groups . However , the rate of increase was significantly less in the cost-sharing group when compared with the non cost-sharing group . Second , the elderly with non-chronic diseases were more sensitive ( i.e. , reducing drug utilization ) to the drug cost-sharing program when compared with those with chronic diseases . Third , for the elderly with non-chronic diseases average drug cost per prescription experienced a smaller decrease in essential drugs but a moderate increase in non-essential drugs for the cost-sharing group . By contrast , for the non cost-sharing group , average drug cost per prescription increased sharply in non-essential drugs as well as essential drugs . Finally , there was a significant increase in the number of prescriptions as well as drug costs above the upper bound of the cost-sharing schedule . The  outpatient drug cost-sharing program  implemented by the NHI in Taiwan did not reverse the trend of prescription drug cost increases in hospitals . The significant increase in the number of prescriptions above the upper bound of the cost-sharing schedule implies that the NHI should increase the upper bound . Further analysis needs to evaluate any adverse clinical impact for older patients result ing from policy changes BACKGROUND Adverse drug-related events are common in the elderly , and inappropriate prescribing is a preventable risk factor . Our objective was to determine whether inappropriate prescribing could be reduced when primary care physicians had computer-based access to information on all prescriptions dispensed and automated alerts for potential prescribing problems . METHODS We r and omly assigned 107 primary care physicians with at least 100 patients aged 66 years and older ( total 12 560 ) to a group receiving computerized decision-making support ( CDS ) or a control group . Physicians in the CDS group had access to information on current and past prescriptions through a dedicated computer link to the provincial seniors ' drug-insurance program . When any of 159 clinical ly relevant prescribing problems were identified by the CDS software , the physician received an alert that identified the nature of the problem , possible consequences and alternative therapy . The rate of initiation and discontinuation of potentially inappropriate prescriptions was assessed over a 13-month period . RESULTS In the 2 months before the study , 31.8 % of the patients in the CDS group and 33.3 % of those in the control group had at least 1 potentially inappropriate prescription . During the study the number of new potentially inappropriate prescriptions per 1000 visits was significantly lower ( 18 % ) in the CDS group than in the control group ( relative rate [ RR ] 0.82 , 95 % confidence interval [ CI ] 0.69 - 0.98 ) , but differences between the groups in the rate of discontinuation of potentially inappropriate prescriptions were significant only for therapeutic duplication by the study physician and another physician ( RR 1.66 , 95 % CI 0.99 - 2.79 ) and drug interactions caused by prescriptions written by the study physician ( RR 2.15 , 95 % CI 0.98 - 4.70 ) . INTERPRETATION Computer-based access to complete drug profiles and alerts about potential prescribing problems reduces the rate of initiation of potentially inappropriate prescriptions but has a more selective effect on the discontinuation of such prescriptions OBJECTIVE To evaluate the effect of emergency department ( ED ) copayment levels on ED use and unfavorable clinical events . Data Source / Study Setting . Kaiser Permanente-Northern California ( KPNC ) , a prepaid integrated delivery system . STUDY DESIGN In a quasi-experimental longitudinal study with concurrent controls , we estimated rates of ED visits , hospitalizations , ICU admissions , and deaths associated with higher ED copayments relative to no copayment , using Poisson r and om effects and proportional hazard models , controlling for patient characteristics . The study period began in January 1999 ; more than half of the population experienced an employer-chosen increase in their  ED copayment in January 2000 . DATA COLLECTION / EXTRACTION METHODS Using KPNC automated data bases , the 2000 U.S. Census , and California state death certificates , we collected data on ED visits and unfavorable clinical events over a 36-month period ( January 1999 through December 2001 ) among 2,257,445 commercially insured and 261,091 Medicare insured health system members . PRINCIPAL FINDINGS Among commercially insured subjects , ED visits decreased 12 percent with the $ 20 - 35 copayment ( 95 percent confidence interval [ CI ] : 11 - 13 percent ) , and 23 percent with the $ 50 - 100 copayment ( 95 percent CI : 23 - 24 percent ) compared with no copayment . Hospitalizations , ICU admissions , and deaths did not increase with copayments . Hospitalizations decreased 4 percent ( 95 percent CI : 2 - 6 percent ) and 10 percent ( 95 percent CI : 7 - 13 percent ) with ED copayments of $ 20 - 35 and $ 50 - 100 , respectively , compared with no copayment . Among Medicare subjects , ED visits decreased by 4 percent ( 95 percent CI : 3 - 6 percent ) with the $ 20 - 50 copayments compared with no copayment ; unfavorable clinical events did not increase with copayments , e.g. , hospitalizations were unchanged ( 95 percent CI : -3 percent to + 2 percent ) with $ 20 - 50 ED copayments compared with no copayment . CONCLUSIONS Relatively modest levels of patient cost-sharing for ED care decreased ED visit rates without increasing the rate of unfavorable clinical events AIMS Cost burdens represent a significant barrier to medication adherence among chronically ill patients , yet financial pressures may be mitigated by clinical or organizational factors , such as treatment aligned with the Chronic Care Model ( CCM ) . This study examines how perceptions of chronic illness care attenuate the relationship between adherence and cost burden . METHODS Surveys were administered to patients at 40 small community-based primary care practice s. Medication adherence was assessed using the 4-item Morisky scale , while five cost-related items documented recent pharmacy restrictions . CCM experiences were assessed via the 20-item Patient Assessment of Chronic Illness Care ( PACIC ) . Nested r and om effects models determined if chronic care perceptions modified the association between medication adherence and cost-related burden . RESULTS Of 1823 respondents reporting diabetes and other chronic diseases , one-quarter endorsed intrapersonal adherence barriers , while 23 % restricted medication due of cost . Controlling for age and health status , the relationship between medication cost and CCM with adherence was significant ; including PACIC scores attenuated cost-related problems patients with adequate or problematic adherence behavior . CONCLUSIONS Patients experiencing treatment more consistent with the CCM reported better adherence and lower cost-related burden . Fostering highly activated patients and shared clinical decision making may help alleviate medication cost pressures and improve adherence Background / Objective Medication reconciliation at transitions of care decreases medication errors , hospitalizations , and adverse drug events . We compared inpatient medication histories and reconciliation across disciplines and evaluated the nature of discrepancies . Methods We conducted a prospect i ve cohort study of patients admitted from the emergency department at our 760-bed hospital . Eligible patients had their medication histories conducted and reconciled in order by the admitting nurse ( RN ) , certified pharmacy technician ( CPhT ) , and pharmacist ( RPh ) . Discharge medication reconciliation was not altered . Admission and discharge discrepancies were categorized by discipline , error type , and drug class and were assigned a criticality index score . A discrepancy rating system systematic ally measured discrepancies . Results Of 175 consented patients , 153 were evaluated .  Total admission and discharge discrepancies were 1,461 and 369 , respectively . The average number of medications per participant at admission was 8.59 ( 1,314 ) with 9.41 ( 1,374 ) at discharge . Most discrepancies were committed by RNs : 53.2 % ( 777 ) at admission and 56.1 % ( 207 ) at discharge . The majority were omitted or incorrect . RNs had significantly higher admission discrepancy rates per medication ( 0.59 ) compared with CPhTs ( 0.36 ) and RPhs ( 0.16 ) ( P < .001 ) . RPhs corrected significantly more discrepancies per participant than RNs ( 6.39 vs 0.48 ; P < .001 ) ; average criticality index reduction was 79.0 % . Estimated prevented adverse drug events ( pADEs ) cost savings were $ 589,744 . Conclusions RPhs committed the fewest discrepancies compared with RNs and CPhTs , result ing in more accurate medication histories and reconciliation . RPh involvement also prevented the greatest number of medication errors , contributing to considerable pADE-related cost savings BACKGROUND There is evidence that pharmacist interventions improve clinical outcomes . The few studies that address economic outcomes ( a ) often report estimated instead of actual medical costs , ( b ) report only medication costs , or ( c ) have been conducted in setting s that are not typical of community-based primary care . OBJECTIVES To ( a ) determine whether a clinical pharmacist 's recommendations to physicians regarding optimizing medication therapy are related to medical costs in capitated patients in an internal medicine practice , and ( b ) compare what primary care physicians ( PCPs ) in a comparison group actually did proactively to optimize medication therapy versus what a clinical pharmacist would have recommended to them . METHODS This was a prospect i ve , controlled study comparing 2 internal medicine practice s. Study enrollment was performed using a screening process carried out every 1 - 2 weeks on a rolling basis for 1 year from July 2001 through June 2002 . Eligibility criteria for prospect i ve enrollment were ( a ) 1 or more risk factors : at least 1 chronic disease or an event ( e.g. , emergency room visit , adverse drug reaction , medication nonadherence ) or aged 50 years or older , ( b ) a scheduled visit to see a PCP within 2 weeks from the screening date or a diagnosis of diabetes without a PCP visit during the first 6 months of the study , ( c ) need for optimization of medication therapy as determined by a clinical pharmacist on the screening date , and ( d ) 12 months of continuous insurance eligibility before enrollment in the study . For inclusion in the final study analyses , patients were also required to have continuous insurance eligibility through 12 months from study enrollment . One clinical pharmacist made recommendations to optimize medication therapy in the intervention group . For the comparison group , the same pharmacist proposed recommendations that remained concealed from the physicians . The primary outcome measure was per patient per year ( PPPY ) medical cost , based on plan liability ( gross allowable costs minus patient costs ) , excluding prescription drug cost . Additional outcome measures included numbers of outpatient visits , hospital admissions , emergency room ( ER ) visits per 1,000 patients , and hospital days ; and percent of recommendations that were accepted by the PCPs . Changes in outcome measures from the pre-intervention to postintervention period were compared across study groups in a difference-indifference analysis , using the Student 's t-test for normally distributed data and the Mann-Whitney U-test ( nonparametric ) for skewed data . RESULTS There were 127 and 216 adult patients in the intervention and comparison groups , respectively . The primary outcome , change in mean PPPY medical ( excluding pharmacy ) cost , did not differ significantly between the groups ( P = 0.711 ) . The between-group difference in the change in ER visits per 1,000 patients approached statistical significance ( P = 0.054 ) . Intervention group patients were more likely than comparison group patients to have the following issues addressed : medication nonadherence ( 85.7 % vs. 40.0 % , respectively ; P = 0.032 ) , untreated indication ( 72.6 % vs. 11.5 % , P < 0.001 ) , suboptimal medication choice ( 60.0 % vs. 5.9 % , P < 0.001 ) and cost-ineffective drug therapies ( 72.1 % vs. 6.5 % , P < 0.001 ) . Of the estimated number of actionable opportunities identified for the comparison group ( but concealed from the physicians ) , 23.5 % were adopted by comparison group physicians without any assistance from a clinical pharmacist . CONCLUSION Compared with patients of PCPs who received no input from a clinical pharmacist  , patients of PCPs who received clinical pharmacist recommendations were more likely to have several medication-related issues addressed , including medication nonadherence , untreated indications , suboptimal medication choices , and cost-ineffective drug therapies . However , total medical ( excluding pharmacy ) costs for the intervention and comparison groups were not significantly different The cost-effectiveness of quality assurance programs is often poorly documented , especially for innovative approaches . The authors analyzed the economic effects of an experimental educational outreach program design ed to reduce inappropriate drug prescribing , based on a four-state r and omized controlled trial ( N = 435 physicians ) . Primary care physicians r and omized into the face-to-face group were offered two individualized educational sessions with clinical pharmacists , lasting an average of 18 minutes each , concerning optimal use of three drug groups that are often used inappropriately . After the program , expenditures for target drugs prescribed by these physicians to Medicaid patients decreased by 13 % , compared with controls ( P = 0.002 ) ; this effect was stable over three quarters . Implementation of this program for 10,000 physicians would lead to projected drug savings ( to Medicaid only ) of $ 2,050,000 , compared with re source costs of $ 940,000 . Net savings remain high , even after adjustment for use of substitution medications . Although there was a ninefold difference in average preintervention prescribing levels between the highest and lowest thirds of the sample , all groups reduced target drug expenditures at the same rate . Targeting of higher-volume prescribers would thus further raise the observed benefit-to-cost ratio from approximately 1.8 to at least 3.0 . Net benefits would also increase further if non-Medicaid savings were added , or if the analysis included quality -of-care considerations . Although print material s alone may be marginally cost-effective , print plus face-to-face approaches offer greater net benefits . The authors conclude that a program of brief , face-to-face “ detailing ” visits conducted by academic rather than commercial sources can be a highly cost-effective method for improving drug therapy decisions . Such an approach makes possible the enhancement of physicians ' clinical expertise without relying on restriction of drug choices OBJECTIVE It is difficult to control drug-prescribing behaviour in general practice , despite the development and distribution of guidelines . The purpose of this study was to assess the effect on drug-prescribing behaviour of implementing prescribing guidelines by means of a reactive computer reminder system ( CRS ) . DESIGN Cluster-r and omised controlled trial with an incomplete block design in the south of the Netherl and s : 25 GPs ( 7 GP practice s ) received reminders about antibiotics and asthma/ COPD prescriptions , 28 GPs ( 7 GP practice s ) received reminders about cholesterol prescriptions . Prescription guidelines were integrated into the computerised GP information system . MEASUREMENTS Both performance indicators and prescription volumes were calculated as the main outcome measures . Next to individual volume measure , sum scores were constructed on the volume measures per drug group ( antibiotics , asthma/ COPD and cholesterol ) . RESULTS Variation between GPs turned out to be larger and more skewed than expected . No differences between groups were found for indicators and volumes related to recommendations advocating certain drugs . Although there was a tendency towards clinical ly relevant results for prescription volumes that were supposed to drop , the difference in sum score between the groups was not significant . For antibiotic prescriptions that were supposed to drop , the sum score for the intervention group was 28.2 ( 95 % CI : 20.8 - 44.5 ) prescriptions per 1000 patients per GP , while this was 39.7 ( 95 % CI : 29.7 - 64.1 ) for the control group ( p 0.2 ) . For prescriptions asthma/ COPD that were supposed to drop , the sum score for the intervention group was 1.1 ( 95 % CI : 0.6 - 2.6 ) prescriptions per 1000 patients per GP , while this was 2.2 ( 95 % CI : 1.4 - 4.3 ) for the control group ( p 0.1 ) . On three specific recommendations ( on quinolones for cystitis , corticosteroids for CPOD , and antibiotics for acute sore throat ) significant differences were found . CONCLUSIONS This study turned out to be underpowered due to high inter doctor variation in prescribing behaviour . Nevertheless , computerised reminders sometimes have a favourable effect on restricting certain drugs that are not or no longer indicated in general practice Background : To be sustainable , pharmacists providing direct patient care must receive appropriate payment for these services . This prespecified sub study of the RxACTION trial ( a r and omized trial of pharmacist prescribing vs usual care in patients with above-target blood pressure [ BP ] ) aim ed to determine if BP reduction achieved differed between patients whose pharmacist was paid by pay-for-performance ( P4P ) vs fee-for-service ( FFS ) . Methods : Within RxACTION , patients with elevated BP assigned to the pharmacist prescribing group were further r and omized to P4P or FFS payment for the pharmacist . In FFS , pharmacists received $ 150 for the initial visit and $ 75 for follow-up visits . P4P included FFS payments plus incentives of $ 125 and $ 250 for each patient who reached 50 % and 100 % of the BP target , respectively . The primary outcome was difference in change in systolic BP between P4P and FFS groups . Results : A total of 89 patients were r and omized to P4P and 92 to the FFS group . Patients ’ average ( SD ) age was 63.0 ( 13.2 ) years , 49 % were male and 76 % were on antihypertensive drug therapy at baseline , taking a median of 2 ( interquartile range = 1 ) medications . Mean systolic BP reductions in the P4P and FFS groups were 19.7 ( SD = 18.4 ) vs 17.0 ( SD = 16.4 ) mmHg , respectively ( p = 0.47 for the comparison of deltas and p = 0.29 after multivariate adjustment ) . Conclusions : This trial of pharmacist prescribing found substantial reductions in systolic BP among poorly controlled hypertensive individuals but with no appreciable difference when pharmacists were paid by P4P vs FFS Abstract Objective : This proof of concept study aim ed to determine whether a pharmacist-managed medication therapy management ( MTM ) program in a private endocrinologist physician ’s practice reduced healthcare services utilization and related costs 6 months after patients ’ discharge from an institution with a transition of care service . Methods : Patients were included in the study if they were English-speaking , ages > 18 years , had type 1 or 2 diabetes , and had a recent transition of care experience ( inpatient hospital stay or emergency department/urgent care/paramedic or other acute care visit ) . The study had a non-r and omized design where intervention patients , enrolled July 1 , 2012–September 30 , 2013 , were administered MTM at four visits over 6 months and were compared to  historical control patients with available electronic medical records from August 8 , 2008 to March 15 , 2012 . The primary study end-point was the rate of 30-day hospital readmissions , as related to the reason for the index admission . Secondary end-points included the cumulative rate of all-cause hospitalizations , emergency department , paramedic and urgent care visits at 30 , 60 , 90 , and 180 days post-discharge as well as imputed total costs , including prescription medication costs , at 180 days . Propensity score weights were constructed to balance covariate characteristics between the intervention and control groups . Weighted multivariate negative binomial and generalized linear regressions were used to model cumulative utilization rates and log-transformed costs , respectively . Results : The intervention ( n = 28 ) and control ( n = 73 ) groups had 0 % hospital readmissions at 30 days post-discharge . In propensity score weighted multivariate analyses , cumulative utilization rate was not different between the two groups ( IRR = 1.61 , p = 0.72 at 180 days ) while costs in the intervention group were lower but not statistically different ( cost ratio = 0.65 , p = 0.13 at 180 days ) . Conclusions : Further studies should investigate whether the integration of pharmacists in transition of care models could reduce readmission and healthcare utilization rates post-discharge BACKGROUND Generic dispensing ratio ( GDR ) is an important measure of efficiency in pharmacy benefit management . A few studies have examined the effects of academic detailing or generic drug sample s on GDR . On July 1 , 2007 , a physician-hospital organization ( PHO ) with a pay-for-performance incentive for generic utilization initiated a pilot generic medication voucher program that augmented its existing pharmacist-led academic detailing efforts . No published studies have examined the role of generic medication vouchers in promoting generic drug utilization . OBJECTIVE To determine if supplementing an existing academic detailing initiative in a PHO with a generic medication voucher program would be more effective in increasing the GDR compared with academic detailing alone . METHODS The intervention took place over the 9-month period from July 1 , 2007 , through March 31 , 2008 .  Vouchers provided patients with the first fill of a 30-day supply of a generic drug at no cost to the patient for 8 specific generic medications obtained through a national community pharmacy chain . The study was conducted in a PHO composed of 7 hospitals and approximately 2,900 physicians ( 900 primary care providers [ PCPs ] and 2,000 specialists ) . Of the approximately 300 PCP practice s , 21 practice s with at least 2 physicians each were selected on the basis of high prescription volume ( more than 500 pharmacy cl aims for the practice over a 12-month pre-baseline period ) and low GDR ( practice GDR less than 55 % in the 12-month pre-baseline period ) . These 21 practice s were then r and omized to a control group of academic detailing alone or the intervention group that received academic detailing plus generic medication vouchers . One of 10 intervention groups declined to participate , and 2 of 11 control groups dropped out of the PHO . GDR was calculated monthly for all pharmacy cl aims including the 8 voucher medications . GDR was defined as the ratio of the total number of paid generic pharmacy cl aims divided by the total number of paid pharmacy cl aims for 108 prescriber identification numbers ( Drug Enforcement Administration [ DEA ] or National Provider Identifier [ NPI ] ) for 9 intervention groups [ n = 53 PCPs ] and 9 control groups [ n = 55 PCPs ] ) . For both intervention and control arms , the GDR for each month from July 2007 ( start of 2007 Q3 , intervention start date ) through September 2008 ( end of 2008 Q3 , 6 months after intervention end date ) was compared with the same month in the previous year . A descriptive analysis compared a 9-month baseline period from 2006 Q3 through 2007 Q1 with a 9-month voucher period from 2007 Q3 to 2008 Q1 . A panel data regression analysis assessed GDR for 18 practice s over 27 months ( 12 months pre-intervention and 15 months post-intervention ) . RESULTS A total of 656 vouchers were redeemed over the 9-month voucher period from July 1 , 2007 , through March 31 , 2008 , for an average of about 12 vouchers per participating physician ; approximately one-third of the redeemed vouchers were for generic simvastatin . The GDR increase for all drugs , including the 8 voucher drugs , was 7.4 points for the 9 PCP group practice s with access to generic medication vouchers , from 53.4 % in the 9-month baseline period to 60.8 % in the 9-month voucher period , compared with a 6.2 point increase for the control group from 55.9 % during baseline to 62.1 % during the voucher period . The panel data regression model estimated that the medication voucher program was associated with a 1.77-point increase in overall GDR compared with academic detailing alone ( P = 0.047 ) . CONCLUSION Compared with academic detailing alone , a generic medication voucher program providing a 30-day supply of 8 specific medications in addition to academic detailing in PCP groups with low GDR and high prescribing volume in an outpatient setting was associated with a small but statistically significant increase in adjusted overall GDR
Increasing the amount of money that people pay for medicines may reduce insurers ' medicine expenditures and may reduce patients ' medicine use .
These types of interventions may lead to small decreases in or uncertain effects on healthcare utilisation .
Cap and co-payment polices may reduce the use of medicines and reduce medicine expenditures for health insurers .
However , they may also reduce the use of life-sustaining medicines or medicines that are important in treating chronic , including symptomatic , conditions and , consequently , could increase the use of healthcare services .
Fixed co-payment with a ceiling and tiered fixed co-payment may be less likely to reduce the use of essential medicines or to increase the use of healthcare services
BACKGROUND Growing expenditures on prescription medicines represent a major challenge to many health systems .
Cap and co-payment policies are intended as an incentive to deter unnecessary or marginal utilisation , and to reduce third-party payer expenditures by shifting parts of the financial burden from insurers to patients , thus increasing their financial responsibility for prescription medicines .
Direct patient payment policies include caps ( maximum numbers of prescriptions or medicines that are reimbursed ) , fixed co-payments ( patients pay a fixed amount per prescription or medicine ) , co-insurance ( patients pay a percentage of the price ) , ceilings ( patients pay the full price or part of the cost up to a ceiling , after which medicines are free or are available at reduced cost ) and tier co-payments ( differential co-payments usually assigned to generic and br and medicines ) .
This is the first up date of the original review .
OBJECTIVES To determine the effects of cap and co-payment ( cost-sharing ) policies on use of medicines , healthcare utilisation , health outcomes and costs ( expenditures ) .