Copayments for prescription medicines on a public health insurance scheme in Ireland

Abstract

. It was presented in poster format and won a poster award in the "Adherence" spotlight session. Key Points:1) The main public health insurance scheme in Ireland (GMS) provides primary care to approximately 40% of the population, generally on a means tested basis, but also on the basis of older age.2) Until 2010 prescription medicines were free at the point of access on this scheme. In 2010 each prescription item was made subject to a €0.50 copayment. This was increased to €1.50 per item in 2013.3) We found that both copayments had a larger impact on adherence to less-essential medicines than essential medicines, consistent with the prior literature. 4) Notably, in comparison to other essential medicines, relatively larger reductions in adherence to anti-depressant medicines were observed after each copayment intervention. 5) Further analyses of our results on anti-depressant medicines, in addition to analyses for clinical outcomes and variability according to socio-economic status within the GMS population, would increase our understanding of the wider impact of this copayment policy. 3 Abstract PurposeWe assessed the impact of the introduction of a €0.50 prescription copayment, and its increase to €1.50, on adherence to essential and less-essential medicines in a publicly insured population in Ireland. MethodsWe used a pre-post longitudinal repeated measures design. We included new users of blood pressure lowering, lipid lowering and oral diabetic agents, thyroid hormone, anti-depressants, non-steroidal anti-inflammatory drugs (NSAIDs), Proton Pump Inhibitors/H2 antagonists (PPIs/H2) and anxiolytics/hypnotics. The outcome was change in adherence, measured using proportion of days covered. We used segmented regression with generalised estimating equations to allow for repeated measurements. ResultsSample sizes ranged from 7,145 (thyroid hormone users) to 136,111(NSAID users). The €0.50 copayment was associated with reductions in adherence ranging from -2.1%[95% CI, -2.8 to -1.5] (thyroid hormone) to -8.3%[95% CI, -8.7 to -7.9] (anti-depressants) for essential medicines and reductions of -2%[95% CI, -2.3 to -1.7] (anxiolytics/hypnotics) to -9.5%[95% CI, -9.8 to -9.1] (PPIs/H2) for less-essential medicines. The €1.50 copayment generally resulted in smaller reductions in adherence to essential medicines. Antidepressant medications were the exception with a decrease of -10.0% [95% CI,] after the copayment increase. Larger decreases in adherence were seen for less-essential medicines; the largest was for PPIs/H2 at -13.5% [95% CI, -13.9 to -13.2] after the €1.50 copayment. Conclusion 4Both copayments had a greater impact on adherence to less-essential medicines than essential medicines. The major exception was for anti-depressant medicines. Further research is required to explore heterogeneity across different socio-economic strata and to elicit the impact on clinical outcomes.5

Cost-Sharing Rates Increase During Deep Recession: Preliminary Data From Greece

“…37 When Ireland started implementing cost containment strategies, a €0.50 copayment per prescription item (capped at €10 per household per month) was introduced on the national tax-funded health insurance program for low-income individuals and older people, which ended free access to prescription medicines. 38 Sinnott et al remark that this small co-payment had little impact on adherence for essential medicines, and a potentially significant reduction in use of less-essential medicines that were overprescribed before the co-payment – they do note. However, there are exceptions and we need a better understanding of the clinical consequences of reductions in use of essential medicines, even if these reductions are small.…”

“…However, there are exceptions and we need a better understanding of the clinical consequences of reductions in use of essential medicines, even if these reductions are small. 38 Ireland has also achieved high compliance with policies related to generic drug use, with researchers mentioning enactment of supportive legislation, acceptability of active-substance based generic substitution and the phased nature of the policy introduction as success factors. 39 Greek policy-makers should explore in detail the measures introduced in Ireland, gain insight, and possibly co-operate with their Irish counterparts in order to contain pharmaceutical costs.…”

The international generalisability of evidence for health policy: A cross country comparison of medication adherence following policy change

“…These results can be found elsewhere. [48] Finally, the policy changes were separated in real time by approximately 10 years. However, we believe that the non-contemporaneous nature of the interventions had minimal impact because our results resembled decreases in adherence observed after a small copayment in a low income population in the 1970s, implying that copayments of small monetary value affect adherence independent of time.…”

Demographic factors and attitudes that influence the support of the general public for the introduction of universal healthcare in Ireland: A national survey

“…Cross sectional analysis of health seeking behaviour within primary care in Ireland revealed that those who had to pay out-of-pocket payments to see a GP were more likely to put off going to the doctor than those with a GMS card (19). Similarly analysis on the impact of the introduction of copayments on prescriptions reported a reduction in medication adherence (20). An antidote to this inequitable two-tiered system is UHC.…”