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The Annals of Pharmacotherapy
■
2005 February, Volume 39
■
339
www.theannals.com
O
ver the past decade, pharmaceutical expenditures and
prices have consistently and substantially exceeded
the rate of inflation.
1,2
Total US expenditures for prescrip-
tion drugs have quadrupled from $40.3 billion in 1990 to
$162.4 billion in 2002, with a projected 2004 expense of
$207.9 billion.
1
The yearly increase in expenditures has
consistently been >10%, with projections of continued
double-digit increases into the foreseeable future. Pharma-
ceutical expenditures are driven by many factors including
increasing utilization due to both a growing and an aging
population, increasing availability of expensive biotech-
nology drugs, and continued rising drug prices exceeding in-
flation.
2-4
During 2003, the top 30 brand-name drugs used by
seniors rose, on average, 4.3 times the rate of inflation.
2
With continued pharmaceutical expenditures spiraling
upward and passage of the Medicare Modernization Act of
2003,
5
it is timely to review the more recent literature on
incentive-based tiered copayment formularies, the widely
used pharmacy benefit cost-control method. Three studies
Are Incentive-Based Formularies Inversely Associated with Drug
Utilization in Managed Care?
Patrick P Gleason, Brent W Gunderson, and Kristin R Gericke
RECENT ADVANCES
Managed Care
OBJECTIVE: To review recent studies comprehensively assessing the impact of incentive-based multitier formularies on pharmaceutical
costs and utilization.
DATA SOURCES: PubMed (2001–December 2003) was searched using the key terms formularies, cost-sharing, and drug costs.
STUDY SELECTION AND DATA EXTRACTION:Studies addressing the impact of implementing multitiered incentive-based formularies as
a central component of an outpatient drug benefit were selected.
DATA SYNTHESIS: One study using pharmacy claims from 25 employers with data from 402786 members modeled the range of
anticipated plan/employer savings associated with single- to 3-tier shifts and found that, going from a single- to 3-tier benefit results
in decreased plan/employer pharmaceutical costs from $650 to $494 (24% decrease) per member per year and decreased
pharmaceutical utilization from 12.3 to 9.4 (23.6% decrease) prescriptions per member per year. Another study demonstrated that
adding an additional tier decreased pharmaceutical utilization, with a dramatic increase in member contribution offsetting the plan’s
expected increase in expenditures. This shift in pharmaceutical expenditures appeared to have no effect on overall medical
utilization over a 3-year follow-up. Finally, a study converting members from a single- to 3-tier incentive-based formulary, associated
with two- to fourfold copayment increases, resulted in a 10% discontinuation rate for angiotensin-converting enzyme inhibitors,
statins, and proton-pump inhibitors among members who were primarily hourly employees. For salaried workers, the addition of a
tier to their benefit appeared to have minimal impact on pharmaceutical utilization.
CONCLUSIONS: Emerging data suggest a potential inverse relationship between pharmaceutical utilization and incentive-based
formularies that increase member contribution to drug costs. Future research should focus on identifying price points and
percentage increases at which members are likely to begin discontinuing necessary medications.
KEY WORDS:cost-sharing, drug utilization, formularies, managed care.
Ann Pharmacother 2005;39:339-45.
Published Online, 11 Jan 2005, www.theannals.com, DOI 10.1345/aph.1E380
Author information provided at the end of the text.
addressing the impact of implementing multitiered incen-
tive-based formularies as a central component of an outpa-
tient drug benefit are examined. In addition, past and fu-
ture pharmacy benefit trends are briefly reviewed.
Evolution of Pharmacy Benefit Tools in the Past
20 Years
The private health insurance industry has responded to
the backlash against their managed care methods of restric-
tive access, capitation, and utilization review. The response
was to re-engineer managed care with a focus on availabil-
ity, product design, consumer cost-sharing, and pricing
policy.
6
As a component of managed care, pharmacy bene-
fit has followed the trend. In the 1980s, a number of differ-
ent pharmaceutical cost-containment methods were used
including restricting pharmaceutical use through closed
formularies with a single copayment for formulary drugs
and non-coverage of non-formulary drugs, as well as uti-
lization management programs (Table 1).
3,4
The pharmacy
benefit has evolved, providing coverage for most outpa-
tient prescription drugs. These less restrictive open formu-
laries were applied using a new copayment structure with
the goal of providing incentives for members to use the
plan’s preferred formulary drugs. This new incentive-
based model featured tiered copayments, where the copay
varies according to the cost of the drug and/or formulary
status (Table 2).
3
The adoption of multitiered benefits has
been widespread and rapid, with one-half to two-thirds of
employees nationally enrolled in 3-tier plans.
3,7
This is
likely due to data documenting substantial employer sav-
ings through the addition of a copayment tier or by in-
creasing copay amounts.
8
Savings through member cost-
sharing may in part be due to deterrence of over-utilization
and greater use of generic drugs.
4
The health plan, and ultimately, the employer, see in-
creased member/employee cost-sharing as one of the few
means to combat ever-increasing pharmaceutical expendi-
tures.
3,4,9
From 1992 to 2002, employers, via private insur-
ers, have paid an increasing share of members’ total drug
expenditures, rising from 27.3% to 47.8% of all US drug
expenditures.
7
During the same period, the consumers’
out-of-pocket payments have dropped from 57.4% to
29.9% of all US drug expenditures. Thus, employers have
shouldered a sizable portion of the ballooning pharmaceu-
tical costs, effectively insulating members from true drug
cost increases. The move to increase member exposure
through greater contribution is seen in the Kaiser Family
Foundation national survey of employers, which docu-
mented the average 2003 prescription copayments and per-
cent increases for each tier of a 3-tier copay from 2000 to
2003.
7
The average 2003 copay and percent increase was
$9.47 (28% increase) for single-tier (generics), $19 (46%
increase) for tier 2 (preferred drugs), and $29 (71% in-
crease) for tier 3 (nonpreferred drugs). A concern with in-
creasing copayments is a decrease in utilization or persis-
tency with which members take their essential medications
for preventing disease exacerbation or events.
3,8,10-21
INCENTIVE-BASED TIERED FORMULARIES IMPACT ON
COSTS AND UTILIZATION
Generally, employers experience the largest savings op-
portunity when an additional tier is added to the incentive-
based formulary.
8
With institution of an added tier, members
are provided incentive to switch to a lower-cost preferred
drug or generic agent. Members who continue to take non-
preferred drugs are required to contribute more, resulting
in lower employer costs. However, some members neither
change to an alternative lower-tier product nor pay the
higher copay for their current nonpreferred drug. They
simply discontinue drug therapy, which may ultimately re-
sult in negative health outcomes and increased medical
costs.
9,15,17,20,21
Any proposed association between increas-
ing cost-sharing and drug utilization requires further elabo-
ration of more specific drug therapy discontinuation predic-
tors. Other potential explanations include lack of member
education about their pharmacy benefit options and sociode-
mographic factors, such as income. Employers and health
plans could employ such information to better understand
and project the ramifications of increasing member contribu-
tions. Current evidence suggests a complex relationship be-
tween incentive-based formularies and prescription drug uti-
lization. For some patient groups, utilization of select drug
classes, such as statins, angiotensin-converting enzyme
(ACE) inhibitors, and branded nonsteroidal antiinflamma-
340
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The Annals of Pharmacotherapy
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2005 February, Volume 39
www.theannals.com
PP Gleason et al.
Table 2. Tiered Copay Designs
a
Copayment (%)
Lifestyle
Tier Generic Preferred Nonpreferred (eg, cosmetic)
Single 10 10 10 10
Two 10 20 20 20
Three 10 20 40 40
Four 10 20 40 80
a
These are examples of possible tiered copayment benefit designs.
Alternative multiple-tier benefit designs may place expensive gener-
ics in the second tier with low-cost brands in the first tier or may dif-
ferentiate brand drugs on tier based on whether a multisource gener-
ic substitute is available.
Table 1. Tools to Control Pharmacy Costs
1980s–1990s Focus 2000 and Beyond Focus
3,4
Closed formularies Open formularies
Single-tier copay Incentive-based (multitier copay), where
Utilization management member pays a fixed amount of pre-
(eg, prior authorization) scription cost, with different amounts
dependent upon tier (see Table 2)
Co-insurance, where member pays % of
prescription cost
Reference-pricing, where member pays
amount above reference price within
drug class
Spending accounts, where member and
plan provide a defined contribution
tory drugs (NSAIDs), was decreased with increasing
member cost-sharing.
14,20,22
For other drug classes, such as
nonsedating antihistamines, proton-pump inhibitors, oral
contraceptives, and statins, this relationship did not exist
among salaried workers.
12,14,23
Limited data are available
suggesting a link between utilization trends driven by in-
centive-based formulary implementation and changes in
healthcare services. The goal of this article is to review re-
cent studies that evaluated the impact of incentive-based mul-
titier formularies on pharmaceutical costs and utilization.
Data Sources
We searched titles and abstracts in PubMed (2001–De-
cember 2003) using the key terms formularies, cost-shar-
ing, and drug costs. Studies were included if the majority
of authors agreed that the studies met the criteria of evalu-
ating incentive-based formularies and comprehensively mea-
suring the impact of an additional copayment tier on overall
drug utilization, health plan (or employer) costs, and member
contribution. Three studies met all criteria (Table 3).
8,12,14
Literature Review
In 2002, Joyce et al.
8
evaluated the relationship between
tiered pharmacy benefit plans and pharmaceutical spend-
ing. Using commercial pharmacy benefit claims from 25
employers with data from 402 786 members, multivariate
regression models were created. These models controlled
for differences in medical benefits and members’ sociode-
mographic comorbidities. The models showed the impact
of single-, 2-, and 3-tier benefits on annual per-member to-
tal pharmacy costs and prescription utilization. Best-fit
models were presented (Table 3). The models can be used
to compare single-tier with 3-tier benefit designs. Costs and
utilization in a 3-tier formulary were approximately 24%
lower than costs and utilization in a single-tier formulary.
This large data set and rigorous multivariate modeling
established the range of anticipated employer savings and
identified that decreasing utilization is a driver in decreas-
ing costs. As it was not a goal of the study, changes seen in
utilization cannot be attributed to the change in tier. The
study design, although strong methodologically from a
multivariate modeling perspective, still had an important
limitation, as it did not follow a population’s pharmaceuti-
cal costs or utilization through a pharmacy benefit transi-
tion (ie, tier addition). Other limitations of the study includ-
ed not assessing medication persistence among essential
and non-essential drugs, medical costs, and the influence of
member contribution in conjunction with utilization shifts.
8
Another study evaluated the effects of a 3-tier copay-
ment system on pharmaceutical and medical utilization
and costs for 12 months after implementation.
12
The study
design was a quasi-experimental pre–post evaluation, with
a comparison group in a population of commercially in-
sured preferred-provider organization (PPO) members, and
included pharmacy and medical expenditures. Evaluating
the impact of adding an additional tier (ie, switching mem-
bers from a 2- to 3-tier pharmacy benefit) was the study
goal. The control group remained with a 2-tier copay formu-
lary, while the intervention group converted from the 2-tier
copay of the control group to a 3-tier copay structure. De-
mographics of control and intervention groups were similar.
The results indicated that, after the intervention, there
were significant pre–post pharmacy cost and utilization
differences between the groups. Additionally, persistence
with drug therapy was compared between the control and
intervention groups. Four classes of drugs for treatment of
chronic disease (estrogens, oral contraceptives, antihyper-
tensives, antilipidemics) were examined. Members who
switched from one medication to another within the drug
class were not considered to have discontinued treatment.
Eleven months after the benefit change, members who
switched to the 3-tier copay had significantly lower utiliza-
tion (76%) of estrogens than members remaining in the 2-
tier copay (84%).
12
However, in a subsequently published
study with 3 years of follow-up, the lower estrogen utiliza-
tion became nonsignificant at 12 months and beyond.
13
There were no pharmacy utilization differences among the
other 3 drug classes.
12,13
These nonsignificant differences
persisted over the 3-year follow-up.
13
This study demonstrated that adding an additional tier
decreased pharmaceutical utilization, with a dramatic in-
crease in member contribution offsetting the plan’s expect-
ed increase in expenditures.
12
Thus, there was cost shifting
of pharmaceutical expenditures from the employer to the
member. This shift in pharmaceutical expenditures ap-
peared to have no effect on overall medical utilization over
the 3 years of follow-up.
12,13
However, the study did not
evaluate persistence of treatment with specific drugs di-
rectly affected by the tier change. For example, if the ma-
jority of the drugs utilized within each of the 4 classes stud-
ied remained in a first or second tier and only a minority
were moved to the third tier, then an assessment of persis-
tence for all drugs within the class is unlikely to have shown
a change because a minority of members were affected.
A study was conducted to determine the effect of 2 dif-
ferent incentive-based formulary design changes on pre-
scription drug utilization and spending within 3 distinct
drug classes: ACE inhibitors, statins, and proton-pump in-
hibitors.
14
Two large employer groups undergoing a switch
in benefit design were selected. Employer A switched
from a single-tier copay structure to a 3-tier scheme. Em-
ployer B switched from a 2- to a 3-tier copay system
(Table 3). The authors identified matched control groups
who were not affected by changes in benefit design. Control
and intervention group utilization and spending in the 3 se-
lected drug classes were compared for the employers.
Among members in Employer A receiving a drug de-
fined after the intervention as a nonpreferred brand (ie,
drug moving to third tier), the study found a greater risk of
discontinuing use of all drugs in a class (relative to
matched controls) for ACE inhibitors, statins, and proton-
pump inhibitors. Approximately one of every 10 patients
who switched from the single- to 3-tier design discontin-
ued their chronic drug therapy in these classes over 6
Association of Drug Utilization with Incentive-Based Formularies
The Annals of Pharmacotherapy
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2005 February, Volume 39
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341
www.theannals.com
342
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The Annals of Pharmacotherapy
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2005 February, Volume 39
www.theannals.com
PP Gleason et al.
Table 3. Evidence Summaries of Reviewed Studies
Study Benefit Result/Comments
Joyce et al. (2002)
8
1-tier (15 plans), mean copay average annual per member pharmacy costs and utilization by plan benefit
Purpose: “In this study, we use data $6.67 ($2–10) 1-tier % difference 2-tier % difference 3-tier
for a wide array of employers and
annual costs per member $650 8 ↓ $598 17.4 ↓ $494
benefit designs to assess how multitier 2-tier (36 plans), mean difference
annual prescriptions per member 12.3 9.8 ↓ 11.1 15.3 ↓ 9.4
formularies, increased copayments, in copay between tiers $7
affect spending.” ($5 generics, $12 brands)
Design: commercial pharmacy benefit
primary goal not to assess the impact of switching tiers; 1- to 3-tier comparison found 24% lower costs and utilization
claims from 25 employers with 55 unique 3-tier (9 plans), $5 generics/
limitations
medical or pharmacy benefit packages $12 formulary brand/$24 non-
no baseline data to compare potential differences between groups; no assessment of medication continuation; no medical
for 75 plan years of data formulary brand
utilization data; member and plan-paid costs not presented separately; no information on what member education materials
claims data 1997–1999
pertaining to new benefit designs provided; significance testing not reported
N = 420786 members with 702782 pt.
years of data; excluded dependents
46.6% ≤45 y of age; 63.9% male; 4 of 10
treated for ≥1 chronic health condition
multivariate regression analyses to create
the best-fit model for 1-, 2-, and 3-tier
populations
Motheral et al. (2001)
12
Control: 2-tier with $7 generic and
pre to post change
Purpose: “Examine the effect of a 3-tier $15 brand; no change during control intervention % difference
prescription copay on pharmaceutical analysis
total pharmacy claims 15.3% ↑ 9.2% ↑ 40 ↓; p < 0.001
utilization and expenditures and use of
plan-paid costs (net) 24.4% ↑ 2.6% ↑ 89 ↓; p < 0.001
other medical resources in a commercially Intervention: preperiod same as
member costs (copay) 15.6% ↑ 50.0% ↑ 320 ↑; p < 0.001
insured population” control
no significant changes in total office or ED visits or hospitalizations for control vs intervention group; continuation of chronic
Design: commercial preferred provider
medications assessed for estrogens, oral contraceptives, antihypertensives, and antilipidemics; no difference between
organization members; 12-month pre and switched to 3-tier $8 generic/$15
control and intervention post continuation rates for oral contraceptives, antihypertensives, and hyperlipidemics; significantly
12-mo post formulary brand/$25 non-
lower (p < 0.01) continuation of estrogens in the intervention group
comparison of intervention vs control group; formulary brand
limitations
claims data 1997–1999
specific chronic drug continuation moved from 2nd to 3rd tier not assessed; no income data reported; no information
Intervention group (N = 6881); mean age
on whether plan members received education on use of new benefit
30.7 y; 52% male; mean chronic disease
score 481
Control group (N = 13279); mean age 30.5 y;
51% male; mean chronic disease score 485
ED = emergency department.
(continued on page 343)
months. Total spending (compared with
matched controls) remained relatively con-
stant in each of the employer groups. In the
group that switched from a single- to 3-tier
design, employer spending decreased by
13–58% for the 3 drug classes and mem-
ber contribution increased by approximate-
ly 120–150%. In the group that switched
from 2 to 3 tiers, employer spending gener-
ally decreased by a smaller amount (~2–5%)
and member contribution increased by about
5%. The effect on medical resource utiliza-
tion was not examined.
14
This study found that incentive-based,
tiered, formulary benefit design changes in-
volving a large shifting of costs to members
were associated with a decrease in pre-
scription drug utilization. Specifically, uti-
lization for both asymptomatic chronic dis-
eases and the symptomatic chronic disease
of gastrointestinal acid disorders was sig-
nificantly lower among members who had
their copay increase from $7 (single-tier)
to either $15 or $30 per month (3-tier)
compared with members not affected by
changes in benefit design. Members who
changed from a 2- to a 3-tier benefit ap-
peared to have less of a decrease in utiliza-
tion compared with members not affected
by changes in benefit design.
14
The study was not designed to draw
conclusions by comparing the outcomes of
the single- to 3-tier conversion group (Em-
ployer A) with those of the 2- to 3-tier con-
version group (Employer B). Due to the
important sociodemographic differences
between members, as well as important
differences in the employers’ comparator
populations, outcome comparisons be-
tween Employer A and B cannot be made.
Employer A had more hourly workers
who likely had lower incomes and in-
creased sensitivity to increases in copay-
ments. In addition, there were differences
in population characteristics between the
intervention groups and their matched con-
trols. On average, for Employer A, those in
the intervention group were younger than
those in the matched control group. For
Employer B, those in the intervention
group were older than those in the matched
control group. If older beneficiaries gener-
ally have more disposable income than
younger beneficiaries, then, relative to
their matched controls, persons in the in-
tervention group in Employer A have less
disposable income to spend on prescrip-
tions than those in Employer B.
14
This
Association of Drug Utilization with Incentive-Based Formularies
The Annals of Pharmacotherapy
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2005 February, Volume 39
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343
www.theannals.com
Table 3. Evidence Summaries of Reviewed Studies (continued)
Study Benefit Result/Comments
Huskamp et al. (2003)
14
Employer group A: 1-tier benefit discontinuation rate among members affected by tier change*
Purpose: “To study responses to the $7 for all prescriptions switched employer group intervention group control group intervention vs control group
introduction of 2 different incentive-based to 3-tier benefit of $8 generic/
ACE inhibitors A 16.2% 6.4% p < 0.001
formularies used by a large health plan and $15 preferred brand/$30
B 8.3% 15.8% p = 0.03
a national pharmacy benefits manager” nonpreferred brand
statins A 21.3% 10.6% p = 0.04
Design: commercial pharmacy benefit
B 9.1% 4.0% p = 0.45
claims from 2 employers instituting Employer group B: 2-tier benefit
a member utilizing a nonpreferred brand experienced a fourfold increase in copay within Employer group A and doubling of
change in benefit structure; utilization $6 generic/$12 brand switched
copay within Employer group B
change of ACE inhibitors, statins, and to 3-tier benefit of $6 generic/
Employer group A had a significant 1 of 10 members discontinue ACE inhibitor or statins vs control group; Employer group B
PPIs within each employer group $12 preferred brand/$24 non-
had a nonsignificant decrease in statin use and a significant increase in ACE inhibitor use
compared with matched control groups preferred brand
limitations
that did not change; included patients
income of beneficiaries not observable; follow-up period after the design change may be too short to offer valid conclusions
filling prescriptions 6 mo before and
about use of ACE inhibitors and statins in the treatment of diseases such as hypertension and hyperlipidemia; little
analyzed drug use in the 6 mo after
information provided on employer groups and time frame of switch; no information on whether members received education
change
on use of new benefit; paradoxical results were observed (discontinuation rate of ACE inhibitors higher in control group); un-
Employer group A (N = 55567; matched
clear whether the control groups’ copays remained stable
control = 55951); hourly workers mean
age 29.6 y (intervention) and 33.5 y
(control); male 54% (intervention) and 52%
(control)
Employer group B (N = 11653; matched
control = 27051); salaried workers mean
age 37.5 y (intervention) and 34.8 y
(control); male 47% (intervention) and 47%
(control)
ACE = angiotensin-converting enzyme; PPI = proton-pump inhibitor.
could affect drug utilization rates. Other studies have found
evidence that lower income level is a risk factor for discon-
tinuing drug use with no changes in benefit structure.
24
Therefore, a conclusion from this study is that a two- to
fourfold increase in copay is likely to result in a 10% dis-
continuation rate for ACE inhibitors, statins, and proton-
pump inhibitors for members who were primarily hourly
employees. For salaried workers, the addition of a tier to
their pharmacy benefit appeared to have minimal impact on
pharmaceutical utilization.
Discussion
Recent studies reviewed have identified that implemen-
tation of an incentive-based multitier formulary is associat-
ed with a cost shift from employers to members and a pos-
sible decrease in pharmaceutical utilization, although, due
to methodologic differences, the studies conflict.
8,12-14
Cre-
ating price sensitivity among members is hoped to provide
incentive for them to more judiciously purchase pharma-
ceuticals, for example, opting for the less expensive generic
agent when available and/or discontinuing an unnecessary
medication. However, discontinuing a necessary medica-
tion may result in future medical problems and expendi-
tures,
21
though current evidence is insufficient to conclude
that a change in pharmacy benefit design is correlated with
medical resource use.
These studies provide evidence that higher out-of-pock-
et expenditures for necessary chronic medications may
have a negative effect on drug therapy persistence. An un-
derstanding of drug persistence during pharmacy benefit
changes requires further investigation, as other explana-
tions for discontinuation include lack of member education
about their pharmacy benefit options and sociodemograph-
ic factors, such as income. Interestingly, consistent with the
findings by Huskamp et al.,
14
another recent study found
patients with higher copays were at greater risk for discon-
tinuing statin therapy.
20
The future of pharmacy benefit management appears to
include increasing copayments and additional tiers.
3,4,9
Fu-
ture research should focus on identifying price points and
percentage increases at which members are likely to begin
discontinuing necessary medications and, if discontinuation
of those medications occurs, determining the subsequent im-
pact on the quality of care. In addition, future research assess-
ing the impact of additional tiers should evaluate switches in
drug class utilization at the member level. For example,
Huskamp et al.’s
14
finding of decreased ACE inhibitor uti-
lization did not assess whether these members switched to
less expensive (lower-tiered) antihypertensives, such as a
generic
β-blocker or generic thiazide diuretic. When con-
ducting these studies, researchers should clearly define the
sociodemographic characteristics of the members studied.
Summary
Until further information becomes available, health
plans and pharmacy benefit managers should be cognizant
of the potential impact copayment increases may have on
utilization and persistence of chronic medications known
to decrease medical events and prevent future medical
complications. As employers strategize and implement
new pharmacy benefits designs to lower drug costs, con-
sideration should be given to the employee population and
level of member contribution. New pharmacy benefits
should consider avoiding excessive member contributions
for drugs known to decrease medical complications, particu-
larly in populations that are cost-sensitive to such changes.
Patrick P Gleason PharmD BCPS, Director of Medical & Phar-
macy Integration Services, Prime Therapeutics, LLC., Eagan, MN;
Clinical Assistant Professor, College of Pharmacy, University of Min-
nesota, Minneapolis, MN
Brent W Gunderson PharmD, Senior Clinical Pharmacist, Prime
Therapeutics, LLC.
Kristin R Gericke PharmD, Associate Clinical Professor of Phar-
macy, School of Pharmacy, University of California at San Francis-
co; Director, Clinical Pharmacy Management, CalOptima, San Fran-
ciso, CA
Reprints: Dr. Gleason, Prime Therapeutics, LLC., 1020 Discovery
Rd., No. 100, Eagan, MN 55121-3497, fax 651/286-4409, pgleason@
primetherapeutics.com
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EXTRACTO
OBJETIVO: Analizar de manera exhaustiva estudios recientes que valoren
el impacto de los formularios con incentivos de varias categorías sobre
el coste y uso de medicamentos.
FUENTES DE INFORMACIÓN: PUBMED (2001–diciembre 2003) con los
términos de búsqueda: formularios, gasto compartido, y coste
farmacéutico.
SELECCIÓN Y OBTENCIÓN DE LA INFORMACIÓN: Se seleccionaron estudios
que abordasen el efecto de la implementación de los formularios con
incentivos de varias categorías como componente central de los
beneficios de farmacia para pacientes no hospitalizados.
RESUMEN: Un estudio de peticiones a farmacia por parte de 25
empleados empresarios y datos de 402 786 beneficiarios, presentó el
margen de ahorro previsto por los planes de asistencia sanitaria y los
empresarios relacionado con las modificaciones en los formularios de
una sola categoría de medicamentos a 3 categorías, y halló que esta
modificación de los beneficios redujo el coste farmacéutico de los
planes y de los empleados de $650 por beneficiario y año a $494
(descenso del 24%) y el uso de medicamentos de 12.3 a 9.4
prescripciones por beneficiario y año (descenso del 23.6%). Otro estudio
demostró que, al añadir una categoría adicional, había una reducción del
número de medicamentos acompañada de un incremento espectacular
en la contribución de los beneficiarios, contrarrestando el incremento
previsto del plan en el gasto. Aparentemente, esta modificación del
gasto farmacéutico careció de efecto en la utilización médica global
durante los 3 años de seguimiento del estudio. Finalmente, un estudio
que analizaba a los beneficiarios que pasaron de formularios con
incentivos de una única categoría a 3 categorías, asociados con
incrementos del copago de 2 a 4 veces, resultó en una tasa de
interrupción del 10% para inhibidores de la enzima conversora de la
angiotensina, estatinas, e inhibidores de la bomba de protones en
beneficiarios que eran principalmente trabajadores por horas. Para
trabajadores asalariados, el aumento de una categoría a su beneficio
aparentemente tuvo un impacto mínimo sobre el uso de medicamentos.
CONCLUSIONES: Los datos obtenidos sugieren una relación potencial
inversa entre la utilización de medicamentos y los formularios con
incentivos que incrementan la contribución de los beneficiarios al coste
farmacéutico. Las investigaciones futuras deberían centrarse en la
identificación de la importancia de los precios y de los incrementos del
porcentaje a partir de los cuales los beneficiarios empiezan a interrumpir
los tratamientos necesarios.
Enrique Muñoz Soler
RÉSUMÉ
OBJECTIF: Réviser les études récentes évaluant l’impact des formulaires
avec plusieurs tiers payeurs basés sur des incitatifs sur les coûts et
l’utilisation de produits pharmaceutiques.
SOURCES DES DONNÉES: Une recherche PubMed (2001–décembre 2003)
avec les mots-clés: formulaires, partage des coûts, et coûts des
médicaments.
SÉLECTION DES ÉTUDES ET EXTRACTION DES DONNÉES: Les études portant
sur l’impact de l’implémentation de régimes à plusieurs tiers payeurs
comme étant l’élément central d’un régime de médicaments de patients
externes ont été sélectionnés.
SYNTHÈSE DES DONNÉES: Une étude utilisant les demandes de
remboursement de 25 employeurs avec des données sur 402786
membres a servi à modeler la plage des économies anticipées par la
modification des régimes de 1- à 3-tiers payeurs. Ce changement a
résulté en une diminution des coûts régime/employeur de $650 par
membre/année à $494 (réduction de 24%) et une diminution de
l’utilisation de 12.3 à 9.4 prescriptions par membre/année (réduction de
23.6%). Une autre étude a démontré que l’ajout d’un tiers payeur
diminuait l’utilisation de médicaments avec une augmentation
significative de la contribution du membre équivalent à l’augmentation
attendue des dépenses du régime. Cette augmentation dans les dépenses
de médicaments ne semble pas avoir d’impact sur l’utilisation de
ressources médicales durant une période de suivi de 3 ans. Finalement,
une étude évaluant le changement d’un régime de 1- à 3-tiers payeurs a
démontré une augmentation des co-paiements de 2 à 4 fois, menant à un
taux d’arrêt de 10% pour les IECA, les statines, et les inhibiteurs de la
pompe à protons qui étaient principalement prescrits à des travailleurs
rémunérés à l’heure. Chez les travailleurs salariés, l’addition d’un tiers
payeur a semblé avoir un impact minime sur l’utilisation des produits
pharmaceutiques.
CONCLUSIONS: Ces données suggèrent une relation inverse possible entre
l’utilisation de produits pharmaceutiques et les régimes qui augmentent
la contribution des membres. Des recherches devraient identifier le
niveau et le pourcentage d’augmentation auxquels les membres
pourraient commencer à cesser des médicaments essentiels.
Nicolas Paquette-Lamontagne
