Unintended consequences of caps on medicare drug benefits
Unintended consequences of caps on medicare drug benefits
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DOI：
10.1056/nejmsa054436
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发表时间：
2006-06-01
影响因子：
158.5
通讯作者：
Selby, Joseph V.
中科院分区：
文献类型：
--
作者：
Hsu, John;Price, Mary;Selby, Joseph V.
背景：关于限制处方药福利对医疗保险受益人的影响的信息很少。方法：我们比较了2003年157,275名医疗保险+选择受益人的临床和经济结果，这些受益人的年度药物福利上限为1,000美元，而41,904名受益人的药物福利因雇主补贴而无限。结果：在调整个体特征后，我们发现福利上限的受试者适用于上限的药物的药房成本比福利没有上限的受试者低31%(95%置信区间，29至33%)，但总医疗成本仅低1%（95%置信区间，-4至6%）。福利被限制的受试者有较高的急诊就诊率（相对率，1.09[95%可信区间，1.04 - 1.14]）、非选择性住院率（相对率，1.13[1.05 - 1.21]）和死亡率（相对率，1.22[1.07 - 1.38]；差异为0.68 / 100人年[0.30 - 1.07]）。在2002年使用药物治疗高血压、高脂血症或糖尿病的受试者中，那些获益被限制的受试者在2003年更有可能不坚持长期药物治疗；分别为1.30（95%置信区间，1.23 - 1.38）、1.27（1.19 - 1.34）和1.33（1.18 - 1.48）的高血压、高脂血症和糖尿病患者的比值比。在每个亚组中，药物获益被限制的受试者的生理结果比获益未被限制的受试者差；对于收缩压为140毫米汞柱或更高、血清低密度脂蛋白胆固醇水平为130毫克/分升或更高、糖化血红蛋白水平为8%或更高的受试者，比值比分别为1.05（95%置信区间为1.00至1.09）、1.13（1.03至1.25）和1.23（1.03至1.46）。结论：药物获益上限与较低的药物消耗和不利的临床结果相关。在慢性疾病患者中，cap与较差的药物治疗依从性以及较差的血压、血脂水平和血糖水平控制相关。上限所节省的药费被住院和急诊费用的增加所抵消。
Background: Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries.Methods: We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at $1,000 and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements.Results: After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more.Conclusions: A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.