Deductibles do not impact asthma medication use, adherence in British Columbia
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Key takeaways:
- Mean annual total expenditures on asthma-related medications was $322.
- The 2% deductible for patients increased medication costs by $48.45.
- The 3% deductible increased medication costs by $27.65.
Income-based deductibles reduced public drug costs without any effect on medication use or adherence in patients with asthma and low incomes in British Columbia, according to a study published in Annals of Allergy, Asthma & Immunology.
But these deductibles did increase costs for patients, Kate M. Johnson, PhD, assistant professor, Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, University of British Columbia, and colleagues wrote.
“We were interested in determining whether patient costs for medications (‘out of pocket costs’) influenced their use of asthma medications and the types of medications they take,” Johnson told Healio.
Fair PharmaCare, which is the universal, high-deductible prescription drug plan for all residents of British Columbia, covers routine asthma-related medications. Deductibles are based on annual household incomes for the previous 2 years.
Deductibles include 0% for households with annual incomes less than $15,000, 2% for those with incomes between $15,000 and $30,000 and 3% for those with incomes greater than $30,000. Once residents meet their deductibles, they pay 30% in co-insurance until they reach a household maximum of 2% to 4% of their annual income.
Study design, results
The study analyzed patients who were aged 5 to 55 years at the time of their asthma diagnosis (mean age, 31 years) with an annual income less than $61,667 who received Fair PharmaCare coverage in any year between 2013 and 2018. The 88,935 patients (57% female) in the study contributed 443,847 person-years during this period.
Also, 8% of the contributing person-years came from patients with incomes less than $15,000, 10% from those between $15,000 and $30,000 and 82% from those with incomes greater than $30,000.
The study also recorded 62,965 individuals with 315,260 person-years who began controlled therapy during the follow-up. The researchers included these patients in calculating medication adherence.
Across all incomes, mean annual total expenditures on medications related to asthma were $322 (standard error [SE], $18), including 4.8 (SE, 0.2) prescriptions each year with 45% (SE, 2.6%) of these medications including inhaled corticosteroids (ICS).
The population also included 35% who received three or more canisters of short-acting beta agonists (SABA), 18% who received six or more, and 7% who received 11 or more. Additionally, the patients who initiated controlled therapy had a 0.3 (SE, 0.01) proportion of days covered (PDC) by controller medications.
Compared with the patients with 0% deductibles, the 2% deductible threshold decreased PharmaCare costs by $41.74 (95% CI, –$28.34 to –$55.13), which the researchers called a relative change of –28% (95% CI, –20% to –35%).
The –$5.22 (95% CI, –$16.68 to $6.23) change in PharmaCare costs with the change from a 2% to a 3% deductible at the $30,000 income threshold was not significant, the researchers said.
Also at the 2% deductible threshold, patient costs grew by $48.45 (95% CI, $35.37-$61.53), which the researchers characterized as a 33% (95% CI, 22%-44%) relative increase.
There was a $27.65 (95% CI, $15.22 to $40.09) increase in patient expenditures at the 3% deductible threshold for a relative increase of 11% (95% CI, 6% to 16%), the researchers continued.
There were no changes in the mean annual number of prescriptions, nor were there any changes in the total dispensed days supply of all asthma medications, at the 2% or 3% deductible thresholds.
Similarly, there were no changes in adherence to controller therapies at the 2% or 3% deductible thresholds based on PDC among the patients who initiated controller therapy, with consistent results in age-stratified analyses.
Also, there were no changes in the ratio of ICS and ICS/long-acting beta agonists (LABA) to total asthma prescriptions, nor were there changes in the ratio of ICS, ICS/LABA and leukotriene-receptor agonists to total asthma prescriptions, at the 2% or 3% thresholds.
These thresholds did not impact excessive SABA use either, consistently across different definitions of excessive use based on canisters per year and in age-stratified analysis, the researchers said, although excessive SABA use decreased with income in all analyses.
Finally, the results for all outcomes did not change when the researchers restricted them to medications that had a primary indication of asthma as well.
Conclusions, next steps
Overall, the deductible increase from 0% to 2% at the $15,000 income threshold, which reduced public drug costs but increased patient costs. The increase from 2% to 3% did not change PharmaCare costs, but it also increased patient costs.
But despite these increased costs for low-income patients, the researchers continued, there were no changes in the asthma medications that were dispensed, in the use of controller therapies that included ICS relative to all asthma medications, adherence to controller medications, or excessive use of SABAs.
“We were surprised that increasing deductibles didn’t cause a decrease in asthma medication use and, in particular, controller medication use,” Johnson said.
“Controller medications are more expensive than reliever medications, and we expected to see patients using more controllers as their out-of-pocket costs decreased,” she continued.
Based on these results, Johnson said, the policy is working as intended, as it decreases costs to the insurer without impacting medication use.
However, the researchers cautioned, future studies should investigate the impacts of other aspects of insurance design since any patient obligations for drug payments may deter medication use.
It is very important to note that deductibles are only one aspect of insurance design, Johnson clarified.
“We’re currently looking at the impact of a policy change that eliminated all patient costs for medications to determine whether it affected asthma medication use,” Johnson said.
“It is very possible that in this low-income group, any medications costs prevented patients from receiving the appropriate medications,” she said.
Doctors also can help patients who may be impacted by these costs, Johnson said.
“Canada is a single-payer insurer and therefore the only option for patients impacted by medication costs is supplemental private insurance,” Johnson said.
But it is important for doctors to consider the costs of medications, and controller medications especially, when prescribing, she continued.
“They should have a conversation with patients about whether paying for their recommended medications is feasible and adjust recommendations accordingly,” Johnson said.
For more information:
Kate M. Johnson, PhD, can be reached at kate.johnson@ubc.ca.
Perspective
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The findings are significant in that they provide insights into the effects of income-based deductibles on asthma management, specifically in lower-income individuals. The study indicates that these deductibles reduced public drug costs but did not affect asthma-related medication use, adherence to controller therapies, or excessive reliever therapy use. This suggests that while cost-related barriers were reduced, patients continued to maintain their medication regimens.
Comparing these findings with the United States is complex due to differences in health care systems and policies. The U.S. has a more fragmented health care system with a mix of public and private insurance. However, similar studies in the U.S. have shown that cost-related barriers can indeed lead to nonadherence, especially in lower-income populations.
These findings also align with my experience and the experience of others that cost impacts adherence and that these cost-related barriers are unfortunately common. Future work may consider the business model of reducing the cost of medications for chronic diseases, such as asthma, and the long-term health care use and cost. We do not have adequate data to say it is cost-effective to further reduce the cost of medications for asthma. Cost effectiveness may differ at the patient, provider and health care system levels.
Doctors can use these findings to emphasize the importance of medication adherence to their patients, even if they have lower incomes and face deductibles. Doctors can discuss strategies to manage costs, such as exploring assistance programs, generic medications or alternative treatment options. Being aware of the financial constraints their patients face can help doctors tailor their treatment recommendations accordingly.
Further, these findings can inform policymakers about the effectiveness of income-based deductibles in reducing public drug costs without negatively impacting medication adherence. Policymakers might consider similar approaches in designing health care policies that aim to balance cost containment with ensuring access to necessary medications.
The next steps in this research could involve studying the long-term effects of income-based deductibles on health outcomes, not just medication adherence. Additionally, future research could explore the impact of deductibles on other chronic conditions and in different health care systems. Qualitative research, like patient interviews, may also provide insights into the patient experience and how deductibles affect their decision-making. Furthermore, investigating the role of education and awareness campaigns in helping patients navigate these changes in health care policy could be valuable.
Perspective
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Although this study did not show any changes in adherence to controller therapies at the deductible thresholds measured by the researchers, it is important to recognize that across all household incomes, studied adherence to controller therapy was suboptimal. The proportion of days covered by controller medications was approximately 30%, meaning 70% of the time patients who needed controller therapies were not receiving them.
As the researchers highlighted, the lack of an impact on medication adherence based on income-based deductible thresholds stands in contrast to what is seen in prior studies in the United States. High out-of-pocket medication costs can be a significant barrier to filling medications for patients in the United States.
Cost and insurance coverage must be taken into consideration when prescribing controller therapies for patients with asthma. Cost-related nonadherence often is overlooked when considering nonadherence among patients. Instead, health care providers often focus on other reasons for nonadherence, such as forgetfulness. It’s critical to explore all potential barriers for why patients may not be taking their daily controller therapies.
I would recommend doctors remember to take into consideration the potential out-of-pocket costs for patients when prescribing medications and realizing that reasons for medication nonadherence are complex, including financial barriers to care.
High deductibles put increased costs on patients, who are then responsible for paying for their daily controller medications. However, if patients are unable to pay for their controller medications, they do not take them, which can lead to asthma exacerbations, ED visits and hospitalizations. These unscheduled health care visits have their own substantial costs. Policymakers need to explore how potential cost savings measures for insurance companies in one domain can lead unanticipated costs for them in another.
Further research should focus on additional deductible thresholds and their impact on cost-related medication nonadherence accompanied by the financial implications of this nonadherence.
Interestingly, while controller medication use was not different across household incomes, SABA use decreased with increased household incomes. Given controller use was the same, that is unlikely to be the reason for less SABA use. Reasons for this discrepancy should be explored. This decreased SABA use may be secondary to disparities in care delivery, specialty access or education, among others.
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