The effect of direct payment policies on people’s use of medicines

Cochrane: Researchers at The Cochrane Collaboration conducted the first update of the original review of the effects of different policies determining how much people should pay for their medicines. Between 2011 and 2013, they searched for all relevant studies and found 32 studies. Their findings are summarised below. Large quantities of healthcare funds are spent on medicines, and these amounts are increasing. Spending more on medicines could mean having less money for other healthcare or non-healthcare services. Also, misuse, overuse and underuse of appropriate medicines can lead to wasted resources and health hazards. Health insurers therefore are looking for ways of ensuring better use of medicines and controlling the costs of medicines, while still ensuring that patients get the medicines they need.

Patient payment policies vary with respect to the medicines included, the patient groups targeted, the amount of money patients are expected to pay and the ways in which they are expected to pay. Different policies may be used alone or together and include the following.
1. With a cap policy, patients are reimbursed for their prescription medicines up to a maximum amount, then are expected to pay costs higher than this amount.
2. With a fixed co-payment policy, patients pay a fixed amount per medicine or prescription.
3. With a co-insurance policy, patients pay a set percentage of the price of the prescription or medicine, rather than a fixed fee.
4. With a ceiling policy, patients pay full cost or part of the cost up to a certain amount, then are given medicines for free or at reduced cost.
These policies may lead people to use fewer medicines or to choose cheaper medicines. Although they may deter people from using unnecessary medicines, these policies may cause harm.
 
Policies that increase the amount of money people have to pay for medicines may reduce insurers’ medicine expenditures and may reduce patients’ medicine use. They may result in a reduction in patients’ use of life-sustaining medicines or other medicines that are important for their health. These types of policies also may lead to small decreases in or uncertain effects on patients’ use of healthcare facilities. No studies have looked at the effects of these policies on patients’ health.

 

 

Authors' conclusions: 

The diversity of interventions and outcomes addressed across studies and differences in settings, populations and comparisons made it difficult to summarise results across studies. 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.