Prescription Drug Insurance Coverage and Patient Outcomes
Prescription Drug Insurance Coverage and Patient Outcomes
Our systematic review of studies evaluating patient health status and health care service use related to possession of prescription drug insurance shows that such programs can have significant effects on both outcomes. Benefits were demonstrated in a variety of clinical circumstances, geographic regions, and temporal settings.
The link between drug insurance expansion and patient health outcomes might be mediated by a number of different mechanisms. One contributor is the improved access to prescription drug therapies offered by enhanced insurance coverage. Patients without insurance may obtain episodic care in an emergency department, but the health effects derived from most prescription therapeutics accrue after ongoing treatment. Consistent access is a key feature of stable insurance coverage. For example, in the Bhattacharya et al. study of outcomes among patients with HIV, the observed improvements in health were a direct result of the life-saving antiretroviral therapy made available to patients through their prescription drug insurance. Clearly, by reducing financial strain on patients, prescription drug insurance helps insulate them from cost-related medication nonadherence and helps advance their health outcomes.
Whether insurance coverage has a positive or negative effect on health care outcomes has become particularly controversial because the Affordable Care Act now authorizes the federal government to offer substantial resources to states for the purposes of expanding Medicaid. Although the federal government plans to cover the full cost of the expansion for the first 3 years and 90% of the cost thereafter, Medicaid expansion has been rejected by some states as too expensive, with state governors expressing worry about excessive spending on Medicaid necessitating cuts to other parts of the government budget. Such perceptions have been buoyed by economic calculations of Medicaid expansion that predict the costs of additional individual enrollees without considering the reductions in costs accruing from the prevention of morbidity associated with use of medications among millions of Americans previously without drug insurance. A key question is whether there would be benefits from the expansion in terms of reduced mortality, and we found limited data addressing mortality directly.
The results of our review are consistent with retrospective studies showing that state-driven Medicaid expansions since 2000 in Wisconsin, New York, Arizona, and Maine have led to reduced mortality and improved coverage, access to care, and self-reported health. A prospective randomized study conducted in Oregon, where a Medicaid expansion was implemented through a lottery process in 2008, also demonstrated better self-reported physical and mental health among those who received health insurance. After 2 years of observation, the experience in Oregon has shown inconsistent effects on health promotion, with significant improvements in access to care and reductions in financial strain from medical costs but insignificant changes in clinical markers of hypertension and diabetes control (however, the study was underpowered for these clinical outcomes).
Notably, effects on health care outcomes or health service use were not observed in all of the studies we identified. In some cases, the effects seen might be explained by the short-term time windows assessed. For example, studying a population sample after only 1 year of coverage, Liu et al. found reductions in out-of-pocket medication costs and increases in prescription drug use but no impact on outcomes. In other cases, negative outcomes may have been consequences of the study designs. For example, Khan and Kaestner found no statistically significant evidence of health benefits in a survey of elderly patients who self-reported changes in health and disability status, in part because their sample also reported limited changes in their use of prescription drugs after obtaining insurance. Their study showed a nonsignificant trend toward beneficial outcomes among a chronically ill subgroup of the population.
Our results should be interpreted with caution given that many of the studies reviewed were conducted during years when costly brand-name drugs were more likely to be prescribed than is the case today, allowing for a greater impact of drug insurance programs. Recently the percentage of prescriptions filled with generic drugs has reached nearly 80% owing to patent expirations of top-selling drugs for a range of different medical conditions. As a result, patients now can be prescribed a wide variety of generic alternatives for many common medication-responsive diseases, such as hypertension and diabetes, offered at prices as low as $4 per month. Use of generic drugs helps address many issues that account for the health benefits of drug insurance, such as cost-related medication nonadherence. Thus, the effect of insurance may be less pronounced in the present-day market, in which generic products are more widely available. Moreover, insurance for generic medications should be rather inexpensive and should promote adherence, which in turn reduces morbidity and its associated costs.
Our conclusions are also limited by the heterogeneity of the studies we identified, many of them examining different aspects of health care delivery and incorporating a variety of methodological approaches and outcome definitions. This heterogeneity prevented us from conducting a quantitative meta-analysis of the results, which would have given greater weight to the findings of the larger studies. To account for heterogeneity, we focused our interpretation on the studies with the largest sample sizes. Another major limitation of our study is the possibility of publication bias. Most of the studies in our sample were retrospective observational investigations, which are not required to be prospectively registered with a trial disclosure database such as ClinicalTrials.gov. Thus, we cannot exclude the possibility that studies were conducted but not completed or published.
Despite the limitations just described, we believe our systematic review shows that substantial evidence supports the central role effective prescription drug insurance can play as policymakers seek mechanisms to reduce the rising health care costs in the United States. Expanding insurance benefits may lead to initial costs in administration, but these costs should be offset by reductions in spending associated with preventable patient morbidity and mortality. Other strategies aimed at increasing the accessibility of essential prescription drugs, such as timely availability of generic alternatives and policies designed to improve medication adherence, will help augment the salutary effects of prescription drug insurance on patient health outcomes.
Discussion
Our systematic review of studies evaluating patient health status and health care service use related to possession of prescription drug insurance shows that such programs can have significant effects on both outcomes. Benefits were demonstrated in a variety of clinical circumstances, geographic regions, and temporal settings.
The link between drug insurance expansion and patient health outcomes might be mediated by a number of different mechanisms. One contributor is the improved access to prescription drug therapies offered by enhanced insurance coverage. Patients without insurance may obtain episodic care in an emergency department, but the health effects derived from most prescription therapeutics accrue after ongoing treatment. Consistent access is a key feature of stable insurance coverage. For example, in the Bhattacharya et al. study of outcomes among patients with HIV, the observed improvements in health were a direct result of the life-saving antiretroviral therapy made available to patients through their prescription drug insurance. Clearly, by reducing financial strain on patients, prescription drug insurance helps insulate them from cost-related medication nonadherence and helps advance their health outcomes.
Whether insurance coverage has a positive or negative effect on health care outcomes has become particularly controversial because the Affordable Care Act now authorizes the federal government to offer substantial resources to states for the purposes of expanding Medicaid. Although the federal government plans to cover the full cost of the expansion for the first 3 years and 90% of the cost thereafter, Medicaid expansion has been rejected by some states as too expensive, with state governors expressing worry about excessive spending on Medicaid necessitating cuts to other parts of the government budget. Such perceptions have been buoyed by economic calculations of Medicaid expansion that predict the costs of additional individual enrollees without considering the reductions in costs accruing from the prevention of morbidity associated with use of medications among millions of Americans previously without drug insurance. A key question is whether there would be benefits from the expansion in terms of reduced mortality, and we found limited data addressing mortality directly.
The results of our review are consistent with retrospective studies showing that state-driven Medicaid expansions since 2000 in Wisconsin, New York, Arizona, and Maine have led to reduced mortality and improved coverage, access to care, and self-reported health. A prospective randomized study conducted in Oregon, where a Medicaid expansion was implemented through a lottery process in 2008, also demonstrated better self-reported physical and mental health among those who received health insurance. After 2 years of observation, the experience in Oregon has shown inconsistent effects on health promotion, with significant improvements in access to care and reductions in financial strain from medical costs but insignificant changes in clinical markers of hypertension and diabetes control (however, the study was underpowered for these clinical outcomes).
Notably, effects on health care outcomes or health service use were not observed in all of the studies we identified. In some cases, the effects seen might be explained by the short-term time windows assessed. For example, studying a population sample after only 1 year of coverage, Liu et al. found reductions in out-of-pocket medication costs and increases in prescription drug use but no impact on outcomes. In other cases, negative outcomes may have been consequences of the study designs. For example, Khan and Kaestner found no statistically significant evidence of health benefits in a survey of elderly patients who self-reported changes in health and disability status, in part because their sample also reported limited changes in their use of prescription drugs after obtaining insurance. Their study showed a nonsignificant trend toward beneficial outcomes among a chronically ill subgroup of the population.
Limitations
Our results should be interpreted with caution given that many of the studies reviewed were conducted during years when costly brand-name drugs were more likely to be prescribed than is the case today, allowing for a greater impact of drug insurance programs. Recently the percentage of prescriptions filled with generic drugs has reached nearly 80% owing to patent expirations of top-selling drugs for a range of different medical conditions. As a result, patients now can be prescribed a wide variety of generic alternatives for many common medication-responsive diseases, such as hypertension and diabetes, offered at prices as low as $4 per month. Use of generic drugs helps address many issues that account for the health benefits of drug insurance, such as cost-related medication nonadherence. Thus, the effect of insurance may be less pronounced in the present-day market, in which generic products are more widely available. Moreover, insurance for generic medications should be rather inexpensive and should promote adherence, which in turn reduces morbidity and its associated costs.
Our conclusions are also limited by the heterogeneity of the studies we identified, many of them examining different aspects of health care delivery and incorporating a variety of methodological approaches and outcome definitions. This heterogeneity prevented us from conducting a quantitative meta-analysis of the results, which would have given greater weight to the findings of the larger studies. To account for heterogeneity, we focused our interpretation on the studies with the largest sample sizes. Another major limitation of our study is the possibility of publication bias. Most of the studies in our sample were retrospective observational investigations, which are not required to be prospectively registered with a trial disclosure database such as ClinicalTrials.gov. Thus, we cannot exclude the possibility that studies were conducted but not completed or published.
Conclusions
Despite the limitations just described, we believe our systematic review shows that substantial evidence supports the central role effective prescription drug insurance can play as policymakers seek mechanisms to reduce the rising health care costs in the United States. Expanding insurance benefits may lead to initial costs in administration, but these costs should be offset by reductions in spending associated with preventable patient morbidity and mortality. Other strategies aimed at increasing the accessibility of essential prescription drugs, such as timely availability of generic alternatives and policies designed to improve medication adherence, will help augment the salutary effects of prescription drug insurance on patient health outcomes.
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