Impact of co-payment level increase of antidiabetic medications on glycaemic control: an interrupted time-series study among Finnish patients with type 2 diabetes

Abstract

Background A new special reimbursement scheme (SRS) for non-insulin medications used for treatment of hyperglycaemia in type 2 diabetes (T2D) was implemented in Finland on January 1, 2017. The new SRS affected all community-dwelling Finnish T2D patients as all community-dwelling residents are eligible for reimbursement for prescription medications. The aim of the study was to evaluate the impact of this co-payment increase on glycaemic control among Finnish T2D patients. Methods Data on glycaemic control were collected with HbA1c measures from electronic health records from primary health care and specialized care in the North Karelia region, Finland, from patients with a confirmed T2D diagnosis in 2012 who were alive on January 1, 2017 (n = 8436). Average HbA1c levels were measured monthly 36 months before and 33 months after the policy change. Consumption of diabetes medications was measured with defined daily doses (DDDs) based on reimbursed medication purchases. Interrupted time series design analysed with segmented regression model was applied to examine the effect of the policy change on average HbA1c levels. Results Eight thousand one hundred forty-three T2D patients had at least one HbA1c measurement within 01/2014–9/2019. Mean age of the patients was 68.1 (SD 11.3) years and 53.0% were women. Average time since T2D diagnosis was 11.5 (SD 6.1) years. An estimated increase of 0.81 (95% confidence interval, CI, 0.04–1.58) mmol/mol in average HbA1c levels was detected at the time of the policy change. In subgroup analyses, strongest effects were detected among patients who used only other diabetes medications than insulin or metformin in 2016 (3.56 mmol/mol, 95% CI 2.50–4.62). Meanwhile, yearly consumption of diabetes medications decreased slightly from 618.9 (SD 487.8) DDDs/patient in 2016 to 602.9 (SD 475.6) DDDs/patient in 2017 (p = 0.048). Conclusions Simultaneously with the increase of the co-payment level, the average HbA1c level increased among T2D patients from the North Karelia region, Finland. This may be explained by the decreased consumption of diabetes medications between 2016 and 2017. Special attention should be allocated to glycaemic control of patients utilizing only other antidiabetic medications than metformin or insulin.

The effect of pharmaceutical co-payment increase on the use of social assistance—A natural experiment study

“…It is possible that some patients stopped buying their medication altogether due to increased cost, or started to use their medication suboptimally to minimize costs. Findings from a regional study reporting a small decrease in medication consumption and an increase in average HbA1c level in affected population after the co-payment increase in 2017 [ 62 ] provide some support for these speculations. Social assistance is also known to be an under used form of financial aid.…”

“…Type 2 diabetes is a common illness, and with Finnish comprehensive register data, we are able to observe medicine purchasing patterns of the entire affected population. Previous study based on medical records from one region in Finland has already shown that the reform coincided with small decrease in the consumption of type 2 diabetes medicines and an increase in the average long-term blood sugar (HbA1c) level, suggesting reduced glycemic control [ 62 ]. A study applying panel survey methods also showed negative development in type 2 diabetes patients’ satisfaction for care, medication use, and increasing experiences of financial difficulties [ 63 ].…”

Citizens’ opinions and experiences related to costs and reimbursements for medications in times of retrenchment: cross-sectional population surveys in 2015 and 2017

“…In 2017, type 2 diabetes medications changed their Special Reimbursement category [ 16 – 18 , 46 , 47 ]. Prior to the reform, the co-payment for all diabetes medicines included in the Special Reimbursement was a €4.50 fixed fee; and after the reform, it was 35% of the retail price.…”

“…Because of the widespread use of newer products (most commonly dipeptidyl peptidase (DPP-)4 inhibitors in combination with metformin), the reform meant notable co-payment increases for many patients, most of whom were older and at the lower end of the income distribution [ 16 – 18 , 48 ]. In 2016, 31% of all patients receiving special reimbursement for type 2 diabetes medicines bought DPP-4-inhibitor products, and 13% bought fixed-dose combination products (typically DPP-4-inhibitor with metformin) [ 39 ].…”

“…In Finland, an increase in medication co-payments has been a recurrent policy used to create savings. Recent studies applying quasi-experimental analytical strategies have shown coinciding negative effects: decreases in the purchasing of medications among patients with schizophrenia and stagnation in the preceding decreasing trend in psychiatric hospitalisations [ 15 ]; decreases in the consumption of type 2 diabetes medications and worsening glycaemic control [ 16 ], and increases in the use of last-resort social assistance vouchers to pay for type 2 diabetes medications [ 17 ]. In longitudinal studies using survey data, increases in financial problems in buying medications and dissatisfaction among people with type 2 diabetes have been observed [ 18 , 19 ].…”