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Abstract Objective: T investigate how prescription o co-payments influence the medicine use of Australian patients. Methods: T surveys and an in-depth wo interview study were conducted in the Newcastle/Hunter region of New South Wales (NSW). A community-based survey explored how often prescription cost posed a barrier to prescription use. A general practice patient survey investigated the impact of prescription cost on the timing of medical consultations and prescription collection. Quantitative data were summar ised using descriptive statistics; associations between household character istics and outcomes were explored using odds ratios and chi square analysis. In-depth interviews were conducted to explore the role of prescription cost in medicine use. The interview data were qualitatively analysed for relevant themes using âgrounded theoryâ. Results: 420 of 950 households (44%) par ticipated in the community sur vey: 110 (26%) reported delaying visiting a GP 85 , (20%) not buying all of their prescription medicines and 77 (18%) not refilling a prescription because of cost. Sixty-two (15%) households repor ted significant difficulties with prescription costs. Households with children had twice the odds of reporting significant difficulties than those without (OR= 2.0, 95% CI 1.2-3.5). Of the 442 (43%) GP patients who par ticipated, 25 (6%) patients reported prescription cost as the reason for delaying their visit. Of the 291 patients who received a prescription, 26 (9%) patients reported cost as the reason for not collecting some or all of their prescriptions. Implications: Given the wide var iation in patientsâ capacity to manage increased outof-pocket costs, co-payments may add to patientsâ burden and place a potential barrier to safe and timely prescription use. ( Aust N Z J Public Health 2004; 28: 62-7) Evan Doran, Jane Robertson, Isobel Rolfe and David Henry School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, Mater Hospital, New South Wales ppro ximately 90% of prescription medicines used in Australia are subsidised through the Phar maceutical Benef its Scheme (PBS),1 the objective of which is to provide universal equity of access to necessary medicines for Australian citizens.2 However, the expenditure required to maintain universal prescription subsidies is increasing by approximately $500 million annually and by 2005 the PBS will cost almost $5.5 billion, a billion dollars more than it cost in 2000/01.3,4 Successive Australian gover nments have attempted to constrain increasing dr ug expenditure by reducing subsidisation coverage and by repeatedly increasing patient contribution to the overall costs (âco-paymentsâ).4-6 Further substantial changes to the PBS (reduction or removal of subsidisation and increases in out-of-pocket expense) could result in loss of equity, with prescription medicines no longer being affordable and therefore less accessib le for many Australians who need them. 3,4 In addition to reducing gover nment drug expenditure, prescription co-payments are used as a behavioural intervention intended to raise âcost consciousnessâ and make patients more pr udent medicine purchasers.7 It is presumed that a propor tion of patient demand represents unnecessary (marginal or sub-optimal) prescription utilisation,4,6 and prescription subsidies are belie ved to contribute to this unnecessar y use.8 Under a subsidised system, where the cost to the user is suppressed, the economic principle of âmoral hazardâ (low cost to the user results in over-consumption) is assumed to operate, resulting in unnecessary medicine use. 9-11 The current PBS community awareness campaign, with its emphasis on reducing âwasteâ, reflects concern about low prescription cost and unnecessary use.12 In response to the âprice signalâ of the copayment, patients should ha ve an incentive to discriminate between services and products that are necessary and those that are marginal or unnecessar y.13 Intended to reduce the âunnecessaryâ medicine utilisation (or âmoral hazardâ), co-payments should discriminate on the basis of the medicine userâs ability-to-benefit rather than on the abilityto-pay and therefore should not reduce use of essential medicines.14 There are, however, considerable prob lems in applying the notion of moral hazard to patient behaviour.15 To access a prescription medicine a patient must first consult with a doctor, the âindispensable pathway to prescription drugsâ.16 Doctors act as agents for patients in the provision of many health services, including prescription medicines. Because of the âasymmetry of knowledgeâ, patients depend on their doctor to advise what treatments are necessary or otherwise. Doctors may or may not take into account the costs of the treatments they prescribe and thus are themselves potentially subject to (provider) moral hazard as much as their patients. While this complicates the analysis of patient behaviour in relation to prescription costs, it is generally neglected in policy decisions to increase co-payments.15 A few studies have examined the influence of prescription cost on how Australian patients use prescription medicines, mostly Submitted: July 2003 Revision requested: September 2003 Accepted: November 2003 Correspondence to: Dr Evan Doran, Clinical Pharmacology, School of Medical Practice and Population Health, Faculty of Health, University of Newcastle, Mater Hospital, Waratah, NSW 2298. Fax: (02) 4960 2088; e-mail: edoran@mail.newcastle.edu.au AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 28 NO. 1 Health Services Research Patient co-payments and use of prescription medicines examining changes in utilisation rates following increases in co-payments. Reflecting the f indings of inter national research,10,16-25Australian studies have consistently shown decreases in prescription utilisation associated with increased patient out-of-pocket cost.26-28 The types of medicines most affected tend to be medicines classified as âdiscretionaryâ i.e. used for symptom relief. The greater decrease in discretionary medicines compared with âessentialâ medicines is interpreted as showing co-payments acting selectively to reduce mostly âunnecessar yâ prescription use.28 However, these studies cannot show directly how prescription cost impacts on medicine-related behaviours at the indi vidual patient level. Regardless of the type of prescription medicine, it is possible that decreases in utilisation may be because cost acts as a barrier to prescription use for some patients. While chronically ill Australian patients have been identified as facing difficulties meeting the cost of their prescription medicines,29 it is possible that other patient groups may also face difficulties. Moderate to low-income patients, par ticularly those not eligible for cheaper prescription access through government welfare arrangements, have been identified as vulnerab le.30 Research overseas has shown that faced with difficulties meeting prescription cost, patients may forgo, reduce or modify their prescription use, potentially compromising their health.21-23,31,32 This paper reports on three studies under taken to examine how prescription co-payments influence the medicine use of Australian patients. Prescription cost was examined as a potential barrier to prescription use but also as a f actor promoting unnecessary demand for prescription medicines i.e. moral hazard. The studies explored the salience of prescription cost in when and how Australians accessed and used prescription medicines, particularly whether prescription cost influenced the decision to seek medical care, to collect prescriptions and to use their drugs safely. Methods Two sur veys and an in-depth interview study were conducted in the Hunter region of New South Wales in 2000/01. The first survey drew on a random sample of the community and attempted to estimate the prevalence of reports of difficulties with prescription costs. This was followed by a second sur vey, targeted at patients attending their general practitioner, which focused on two issues identified in the first sur vey: the timing of seeking medical care and prescription collection. The interview study collected qualitative data on the role of cost in prescription use and was conducted after the completion of the f irst survey and concur rent with the second survey. Community survey. A questionnaire w as sent to 1,000 residents randomly drawn from the electoral roll for the Newcastle/ Hunter region. To ensure a 95% confidence interval for proportions of no wider than ± 5%, approximately 400 completed questionnaires were required. With an expected response rate of around 40% (based on earlier local survey experience) a sample of 1,000 was necessar y. 2004 VOL. 28 NO . 1 The questionnaire included seven items that asked about three types of medicine-related behaviours judged to be indicative of difficulties with prescription cost. Respondents were asked whether in the last six months, because of the prescription cost, any member of their household had: delayed visiting their GP; not collected prescription medicines; or altered the way they used their prescription medicines (for example, by reducing the dose). These questions were asked using a Yes/No response format. Respondents reporting all three types of behaviour were judged to have signif icant dif ficulties with prescription cost. The questionnaire included an eight-item scale (using Likert response format) asking about the degree of concern associated with prescription cost. A scale score was derived (range=8-32) and divided into three equal strata (score 8-16=little or no concern; 17-24=some concern; and 25-32=signif icant concern). The questionnaire also included one item asking whether prescription cost was believed to be fairly priced or too expensive; two items asking whether prescription cost was discussed with the doctor; and a set of questions asking about household demographic characteristics (see Appendix). General practice patient survey. Forty-six general practitioners from 20 surgeries participated in the study. The surgeries represented 18 Hunter region post codes and were recruited with the assistance of the Hunter Urban Division of General Practice. Surger y staff compiled a list of the names and addresses of all patients attending a participating GP on a specif ied day. All listed patients (1,036) were mailed the questionnaire 5-7 days after their consultation. The questionnaire asked: whether the patient had delayed seeing the doctor and the reason for the delay; whether medicine(s) had been prescribed, and whether they had been collected. If a prescription was not collected, respondents were asked for the reason and the medicine type. In contrast to the community survey, the GP patient survey allowed people to nominate their reasons from a list. This allowed prescription cost to emerge as a reason without being directly solicited. Household demographic characteristics were also recorded (see Appendix). Statistical analysis Statistical software (SPSS v ersion 10) was used to analyse the data.33 Conventional descriptive statistics were used to summarise the data and proportions were calculated with 95% confidence inter vals. In the community survey, the respondent household was the unit of analysis; the individual patient the unit of analysis in the GP patient survey. Associations between demographic characteristics and difficulties or concer n with prescription cost were explored using odds ratios and chi square analysis. Interview study. In-depth inter views were conducted with respondents from the community sur vey who were willing to be inter viewed and were available during the study period (n=33). The interviews lasted between 50 minutes and two hours (one hour average). The interviews were designed to elicit accounts of prescription use where the influence of prescription cost could emerge as signif icant or otherwise. The interviews were recorded and transcribed verbatim. The interview data were qualitatively AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Doran et al. Article analysed for major themes following the âgrounded theor yâ method.34 The units of analysis were the relevant concepts (ideas, objects, events or actions) in inter vieweesâ accounts of prescription use. The interview transcripts were coded for concepts, with coded segments then anal ysed and categorised thematically. Relationships between concepts and themes were explored to identify the connections between contextual f actors and the actions of individuals.34 One-third of the interviews were coded on two occasions to ensure consistency in coding. âNegative case testingâ (identifying cases that do not suppor t the findings) was performed to ensure that the interpretation reflected the content of the data.35 Interviewees were provided with an edited interview transcript and a summary of the analysis with an invitation to check that their views had been accurately represented.36 This repor t outlines the main f indings of the interview study relevant to prescription cost influencing the decision to seek medical care, prescription collection and appropriate use. A fuller discussion of the f indings of the inter view study will be reported elsewhere. The studies were approved by the Human Research Ethics Committee of the University of Newcastle. Table 2: Community survey â reported behaviours because of prescription cost. n (n=420) Delayed seeing GP because of cost of prescription medicines Used a medicine at home from a previous illness because of cost of new prescription Not able to buy all of the medicines prescribed because of the cost Not able to get a refill of a prescription because of cost Shared a medicine prescribed for one person between family members because of the cost of a new prescr iption Reduced dose of a prescription medicine because of the cost Used a medicine prescribed for someone else because of cost 110 107 95% CI 22-30 21-30 16-24 15-22 8-16 8-14 7-13 Results After excluding undeliverable questionnaires, 420 of 950 (44%) participated in the community survey. In the GP patient survey, 442 of 1,036 patients (43%) participated. In both sur veys, respondents were less likely to be working full time and more likely to have a Health Care Card or similar (e.g. veteranâs card) than the Australian population (see Table 1). Interviewees (22 female, 11 male) were from diverse backgrounds, financial status and ages (19-83 years). Community survey Overall, 188 (45%) respondents reported cost as influencing their prescription use. Delaying a visit to the GP because of prescription cost was the most frequently reported behaviour, followed by not buying all prescribed medicines and not ref illing a prescription (see Table 2). The most frequently reported behaviours with implications for safe prescription use were: consuming a medicine prescribed for a previous illness; sharing a medicine prescribed for one person between family members; reducing the Table 1: Respondent household characteristics. Characteristic Community GP survey Aust. sur vey % % popn % (n=420) (n=442) 85 40 65 78 69 29 56 60 52 76 36 77 39a prescribed dose, and using a medicine prescribed for someone else (see Table 2). A total of 62 (15%) respondents repor ted delaying visiting their GP not collecting some or all of the prescrip, tion medicines, and altering the way prescription were used and were judged to have significant difficulties with prescription cost. The only demographic characteristic shown to be associated with significant difficulties was the presence of children. Households with at least one child below the age of 18 years had twice the odds of being judged to have âsignificantâ difficulties with prescription cost compared with those with no children (OR = 2.04, 95% CI 1.18-3.51). In all, 288 (69%) respondents indicated some concern about prescription cost, with 63 indicating significant concern (see Table 3). Of these 63, 27 (43%) also repor ted signif icant difficulties. That is, 36 respondents experienced significant concern but did not report engaging in all prescription medicine behaviours. Two hundred and seventy-three (65%) respondents indicated that prescription medicines were âtoo expensiveâ. Despite this, a minority (41%) of households reported discussing prescription cost with their general practitioner (see Table 4). General practice patient survey Of the 168 (38%) patients who repor ted delaying seeing their â¥2 adults Children â¥1 adult working full/par t time â¥1 member requiring regular prescription medicine Table 3: Concern associated with meeting prescription costs. Concern score Not concerneda Some concern n (n=420) 95% CI 27-36 49-58 12-19 â¥1 member with Health Care Card 50 Significant concernc Note: Scale score = a8-16, b 17-24, c25-32. Note: (a) Figure is for individuals not household. AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH VOL. 28 NO. 1 Health Services Research Patient co-payments and use of prescription medicines GP 25 (15%) patients cited prescription cost as the reason for the , delay (see Table 5). Of the 291 patients who received a prescription, 61 patients (21%) reported not collecting medicines, of whom 26 cited prescription cost as the reason for not collecting some or all of the medicines prescribed (see Table 6). The prescriptions not collected because of cost included important medicines, such as anti-hypertensives. Only two demographic characteristics were statistically signif icantly associated with the outcomes. Patients from households without access to a Health Care Card had increased odds of reporting delay in seeing their GP (OR=2.8, 95% CI 1.2-6.5). There were also small differences between income groups with seven (10.4%) of those in the middle income group reporting not collecting a prescription compared with 14 (6.3%) of those in the lower and two (1.8%) in the higher income g roups (chi square=6.256, df =2, p=0 .04). Table 5: GP patient survey â Reason for waiting before visiting the doctor.a Reason Thought the condition would improve Unable to make an earlier appointment Cost of the prescription medicine Donât like visiting the doctor Cost of the consultation Concern about diagnosis Other Note: (a) Respondents could choose more than one reason. n=168 Interview study The major themes identif ied in the analysis were an ambivalence and reluctance about using prescriptions and the importance of establishing the necessity for prescription use. Reflecting the findings of the community sur vey, a minority of the interviewees reported prescription cost as affecting when and how they used prescription medicines. However, for the majority of interviewees, prescription cost per se did not feature importantly in the decision to access and use a prescription medicine. Typically, the time, effort, cost and inconvenience associated with a medical visit were described as making a medical visit unlikely until it was felt necessary. Once the decision to seek medical care had been made, associated costs were expected. While interviewees did not always expect that their doctor would prescribe a medicine, and most expressed a wish for medicines to be unnecessary, it was generall y accepted that a prescription would often result. The offer of a prescription was typically accepted as an expression of expert clinical judgement. The necessity of a prescription and non-pharmaceutical alternatives were described as being occasionally discussed, although not usually in relation to cost. In most circumstances, cost was at most a secondar y consideration in the decision to accept a prescription. Whether anticipated as affordable or otherwise, prescription cost appeared as a f actor subordinate to the perceived necessity of the medicine and the potential for adverse effects. For most interviewees, the necessity of a medicine was established in the doctor having prescribed it. Having been prescribed a medicine, most interviewees declared they would f ill the prescription regardless of the cost (unless the doctor explicitly left it to their discretion). No interviewee described a prescription becoming more necessary or more acceptable simply because it was affordable. Having judged a medical visit necessar y, and having invested time, effort and money in visiting the doctor (a trusted expert), to not obtain a prescription because of the cost was described as making little sense. This held even for those medicine users who experienced difficulties affording prescription cost; most reported accommodating prescription cost by curtailing other spending and continuing to seek medical care where necessary, and using medicines when prescribed. Far from being a salient feature of the consultation, prescription cost was only occasionally discussed with the doctor and, typically, this was only when the doctor initiated the discussion. Prescription cost was described as not a matter pertinent to a doctor prescribing on the basis of medical need. Where cost did feature more prominently in the decision, a review of prescription necessity on the basis of cost was much less likely than a review Table 6: GP patient survey â Reason for not collecting medicine(s) prescribed. a Reason Cost of the prescription Had the medicine at home The doctor left the decision to collect to me Thought the condition would improve Worried about side effects Donât like taking medicines Reasons supplied by respondent â Sample provided by doctor Table 4: Community survey â frequency of discussing prescription cost with the doctor and opinion on prescription cost. Never Sometimes Often How often have you talked with your GP about the cost of the medicines he/she prescribes for you? 245 (58%) 152 (36%) 17(4%) n=291 Al ways 6 (2%) Too expensive In you opinion are prescription medicines ... 65% Fairly priced 23% Unsure 12% â Medicine not immediately required â Other Note: (a) Respondents could choose more than one reason. 2004 VOL. 28 NO . 1 AUSTRALIAN AND NEW ZEALAND JOURNAL OF PUBLIC HEALTH Doran et al. Article of the patientâs capacity to manage the cost. The latter appeared more likely where âability to payâ w as limited. Discussion Prescription co-payments are intended to raise the salience of cost in prescription use and modify patient behaviour without presenting a bar rier to pharmaceutical access. The studies combine to show a picture of prescription use where necessity, trust in doctorsâ expertise and a wariness of medicines dominate. The studies confirm that prescription cost can pose difficulties for some Australians. Consistent with the findings of the Australian arm of a recent five-nation survey, 37 the community survey found that for almost 20% of respondents prescription co-payments influence when and how they access and use medicines. Prescription cost w as cited as the reason for delays in seeking care, for not collecting prescriptions and for altering how they used medicines. The GP survey confirmed that prescription cost influences the timing of consultation. These results may suggest that prescription cost induces âappropriateâ behaviour, acting as a disincentive to unnecessary medical visits. However, the inter views suggested that prescription cost, at least on some occasions, acted to deter people from seeking medical care when unwell. The commonly held belief that a GP consultation will often result in a medicine being prescribed and a cost incurred (in addition to the cost of the consultation itself) deterred the prospective patient from seeking timely, appropriate professional care. Both surveys also showed that prescription cost can influence the decision to collect a prescription medicine. This may indicate that prescription cost promotes more pr udent use of prescription medicines. However, the GP survey showed that the types of medicine not collected included anti-hypertensives, suggesting a response to cost with potentially serious health implications. Further, similar to studies overseas30,31 we found that prescription cost can influence safe prescription use with some respondents reporting sharing medicines, using medicines prescribed for others and reducing the prescribed dose as a means of coping with cost. For the majority of participants, however, prescription cost did not appear as either salient or as a reason for modifying prescription use. In the community survey, more participants reported being concerned about prescription cost and believing cost to be too expensive than reported modifying their medicine-related behaviours. The majority of people in the community sur vey and the inter view study reported that they did not talk to their doctor about prescription cost. Many interviewees expressed the belief that prescription cost was not an appropriate or a relevant matter to be discussed with the doctor, a f inding reflected in a recent UK study.38 This key factor has been noted elsewhere for Australian patients.39 The interviews showed that prescription cost was an expense that patients often expected to result from a medical visit. They believed that a medicine was prescribed because the doctor judged it necessary and would meet the cost where they were able to do so. Once in a doctorâs surgery, the patient is âin the systemâ and if âwilling to payâ overstates the case, then perhaps âexpect to payâ better characterises the experiences of many medicine users. This expectation appeared to reduce the salience of cost in the decision to accept a prescription during the consultation. The study had a number of limitations. Response rates were moderate, 44% in the community and 42% in the GP patient survey, and the samples differed from the Australian population on a number of characteristics. The small samples used limited the scope for identifying subgroups of patients at risk of experiencing difficulties with prescription cost. Conclusion The studies suggest that prescription cost influences the safe and timely use of prescription medicines for a signif icant minority of Australian medicine users. For most patients, however, medicine use continues uninterrupted by prescription cost even w here cost is perceived to be too expensive and is the cause of concer n. The results also suggest that prescription cost is only occasionally prominent in the decision to accept a prescription medicine, that few patients review the necessity of a medicine on the basis of prescription cost, and that many do not discuss cost with their doctor. Prescription cost may cause difficulties or concerns that are simply overcome because of the importance placed in the use of a medicine that a doctor has prescribed. The apparent lack of cost-consciousness in the decision to accept a medicine when one is prescribed did not appear to make medicine use more appealing to the medicine users we interviewed. Prescription medicines do not appear to become more or less necessary because of their cost. Future increases in co-payments may do little more than shift more of the cost to the patient, who will likely attempt to meet the cost of the necessary prescription regardless of the difficulty. Ultimately, given the wide variation in patientsâ capacity to manage increased out-of-pocket costs, co-payments may add to patient burden and place a potential bar rier to safe and timely prescription use.
Australian and New Zealand Journal of Public Health – Wiley
Published: Feb 1, 2004
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