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IIR 03-200 – HSR&D Study

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IIR 03-200
VA Prescription Drug Company Copayments and Veterans with Diabetes or Hypertension
Matthew L Maciejewski PhD
VA Puget Sound Health Care System Seattle Division, Seattle, WA
Seattle, WA
Funding Period: January 2004 - September 2006

BACKGROUND/RATIONALE:
The purpose of our project was to evaluate the impact of the increase in the VA medication copayment in February 2002 from $2.00 to $7.00 per 30-day fill on medication adherence, disease control, VA utilization and expenditures of veterans with diabetes and/or hypertension.

OBJECTIVE(S):
The purpose of this study was to examine: (1) the effect the VA's medication copayment increase on changes in medication use by veterans with diabetes and/or hypertension, (2) the effects of medication changes on VA utilization and costs by veterans with diabetes, veterans with hypertension and veterans with both conditions and (3) the effects of medication changes on intermediate health outcomes (e.g., HbA1c, blood pressure, LDL).

METHODS:
In a longitudinal retrospective cohort study of 2,426 veterans with diabetes and 7,731 veterans with hypertension, we estimated pre-post changes in adherence to oral hypoglycemic agents, anti-hypertensives, and statins; we also measured disease control, VA utilization, and VA expenditures in 2000-2004 using generalized estimating equations. The unit of analysis was the person-month. All models controlled for copay exemption, a pre-post indicator, time, demographics, patient risk, lagged outpatient visits to account for outpatient visit copayments instituted in December 2001, and the number of other medications that the patient was currently taking.

FINDINGS/RESULTS:
The medication copayment was associated with reduced adherence to oral hypoglycemic agents, but was not associated with adherence to anti-hypertensives or statins. Veterans with diabetes and/or hypertension required to pay copayments had significantly lower numbers of primary care visits and lower primary care expenditures than veterans exempt from copayments after February 2002, which was most likely to due health care copayment increases that occurred two months prior to the medication copayment increase. There was no discernible impact on blood sugar or blood cholesterol control.

IMPACT:
This project demonstrates that a $5 increase in medication copayments (from $2 to $7) was sufficiently large to induce non-adherence to oral hypglycemic agents, but not large enough to induce non-adherence to anti-hypertensive medications but not large enough to affect adherence to anti-glycemic medications or statins. Before undertaking additional medication copayment increases, VA must understand how its medication copayment policies affect veterans who rely upon medication management for their chronic conditions.

PUBLICATIONS:

Journal Articles

  1. Smith VA, Maciejewski ML, Olsen MK. Modeling Semicontinuous Longitudinal Expenditures: A Practical Guide. Health services research. 2018 Aug 1; 53 Suppl 1:3125-3147.
  2. Wong ES, Maciejewski ML, Liu CF. Does the association between prescription copayment increases and medication adherence differ by race? Journal of health care for the poor and underserved. 2013 Aug 1; 24(3):1317-30.
  3. Herrin MA, Feemster LC, Crothers K, Uman JE, Bryson CL, Au DH. Combination antihypertensive therapy among patients with COPD. Chest. 2013 May 1; 143(5):1312-20.
  4. Maciejewski ML, Liu CF, Kavee AL, Olsen MK. How price responsive is the demand for specialty care? Health economics. 2012 Aug 1; 21(8):902-12.
  5. Wong ES, Piette JD, Liu CF, Perkins M, Maciejewski ML, Jackson GL, Blough DK, Fihn SD, Au DH, Bryson CL. Measures of adherence to oral hypoglycemic agents at the primary care clinic level: the role of risk adjustment. Medical care. 2012 Jul 1; 50(7):591-8.
  6. Wang V, Liu CF, Bryson CL, Sharp ND, Maciejewski ML. Does medication adherence following a copayment increase differ by disease burden? Health services research. 2011 Dec 1; 46(6pt1):1963-85.
  7. Maciejewski ML, Livingston EH, Kahwati LC, Henderson WG, Kavee AL, Arterburn DE. Discontinuation of diabetes and lipid-lowering medications after bariatric surgery at Veterans Affairs medical centers. Surgery for obesity and related diseases : official journal of the American Society for Bariatric Surgery. 2010 Nov 1; 6(6):601-7.
  8. Maciejewski ML, Bryson CL, Perkins M, Blough DK, Cunningham FE, Fortney JC, Krein SL, Stroupe KT, Sharp ND, Liu CF. Increasing copayments and adherence to diabetes, hypertension, and hyperlipidemic medications. The American journal of managed care. 2010 Jan 1; 16(1):e20-34.
  9. Maciejewski ML, Liu CF, Fihn SD. Performance of comorbidity, risk adjustment, and functional status measures in expenditure prediction for patients with diabetes. Diabetes Care. 2009 Jan 1; 32(1):75-80.
Conference Presentations

  1. Smith V. Models for Longitudinal Semicontinuous Data. Paper presented at: International Biometric Society Annual Conference; 2016 Jul 10; Victoria, Canada.
  2. Maciejewski ML, Wang V, Bryson C, Liu CF. Does Veteran Adherence to Medications Following VA Medication Copayment Increase Differ by Disease Severity? Poster session presented at: AcademyHealth Annual Research Meeting; 2010 Jun 28; Boston, MA.
  3. Maciejewski ML, Farley JF, Wansink D. Turning the Tide? Medication Adherence after Copayment Reductions - Plenary Presentation. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 29; Minneapolis, MN.
  4. Maciejewski ML, Bryson CL, Perkins M, Sharp N, Liu CF. Which Veterans Were Most Adversely Impacted by the VA Medication Copayment Increase? Paper presented at: American Society of Health Economists Biennial Conference; 2008 Jun 23; Durham, NC.
  5. Liu CF, Bolkan C, Chan D, Yano E, Chaney E. Dual Use of VA and Non-VA Services among Primary Care Patients with Depression. Presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC.
  6. Maciejewski ML, Bryson CL, Perkins M, Sharp N, Liu CF. Which Veterans Were Most Adversely Impacted by the VA Medication Copayment Increase. Poster session presented at: AcademyHealth Annual Research Meeting; 2008 Jun 9; Washington, DC.
  7. Bryson CL, Liu CF, Sharp ND, Perkins M, Blough DK, Boyko EJ, Maciejewski ML. Combined Medication Adherence to Cardiovascular Risk Reduction Therapy. Poster session presented at: Society of General Internal Medicine Annual Meeting; 2008 Apr 9; Pittsburgh, PA.
  8. Bryson CL, Liu CF, Sharp ND, Perkins M, Blough DK, Boyko EJ, Maciejewski ML. Combined Medication Adherence to Cardiovascular Risk Reduction Therapy. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  9. Maciejewski ML, Bryson CL, Perkins M, Sharp N, Liu CF. Which Veterans Were Most Adversely Impacted by the VA Medication Copayment Increase? Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD.
  10. Bryson CL. Prescription Drug Copayments and Veterans with Hypertension. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  11. Smith BM, Stroupe KT, Lee TA, Tarlov E, Huo Z. Discontinuation of VA Pharmacy Use for Chronic Medications after the Copayment Increase. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.
  12. Stroupe KT, Smith BM, Lee TA, Tarlov E, Huo Z, Barnett T. Effect of Medication Copayment Increase on Medication Acquisition. Poster session presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.


DRA: Health Systems
DRE: Prevention
Keywords: Cardiovasc’r disease, Diabetes, Risk factors
MeSH Terms: none

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