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Prescription Drug Benefit Dispensing Restrictions Barrier to


									Prescription Drug Dispensing
A Barrier to Managing Chronic
   Conditions And Costs?
     Phillips KA, Liang SY, Haas J,
        Stebbins M, Alldredge B
  University of California, San Francisco
            Harvard University
      Funding from NCI & AHRQ
Our “Strange” Attitudes
    Towards Drugs
            Did You Know?
• Private health plans limit prescriptions to
  30-day supply when filled at community
  – >30-day supply only if mail order or self-pay
  – Some scrips should only be filled for 30-days
    or less but
• Medicines used for chronic illness may
  often be appropriately filled for > 30 days
      And This is News!

Medicare scrip benefit covers
 scrips for > 30 days at
 community pharmacies
              Why Care?

Why important?

Dispensing patterns   adherence   outcomes

    Yet virtually NO research on
         dispensing patterns!
• Examine dispensing patterns for five
  drug classes for chronic conditions
  –   Antidepressants (AD)
  –   Antiepileptic drugs (AED)
  –   Beta-blockers (BB)
  –   Hormone replacement therapy (HRT)
  –   Oral contraceptive pills (OCP)
• Examine expenditures for 30-day vs >
  30-day supplies
          Using Linked Data
• 1996 & 2000 Medical Expenditure
  Panel Surveys
  – Nationally representative data
  – Data obtained from households then linked to
• Most comprehensive and accurate data
  available to our knowledge
  – But data do not enable examining outcomes of
              Who & Why?
• Ongoing users only
• To categorize dispensing patterns must:
  – Identify specific drugs (brand & generic names)
  – Identify standard dosing patterns
             This is hard work!!
• Chose 5 drugs
  – Represent 20% of sales in US
                  What Drugs?
• Selected range of drugs:
  –   Commonly prescribed
  –   Used for chronic conditions
  –   Safe to dispense > 30 days
  –   Consistent dosing patterns
  –   Variety of populations
       • One gender vs. both
       • All ages vs. younger vs. older
            Study Populations
• Both genders and all ages for antidepressants
  (N=738) and antiepileptic drugs (N=306)
• Both genders and ages 18+ for beta-blockers
• Females ages 50+ for hormone replacement
  therapy (N=878)
• Female ages 18-35 for oral contraceptives
           Outcome Measure
• Prescriptions categorized as <=30 days or >
  30 days
  – Based on pharmacy-reported quantity dispensed
     • Also RX strength and RX form
  – Three approaches to identify drug names and
    standard dosing patterns:
     • ePoctrates
     • Drug Information for the Health Care Professional
     • Clinical experts
 Results: Majority Get < 30 Days
• Majority obtained <30-day supplies
   – 62% in 1996
   – 66% in 2000
• Low use of mail order services
   – 12% in 1996
   – 14% in 2000
• Different patterns by drugs
   – Higher % <30 day scrips if oral contraceptives, anti-
     epileptic drugs, & anti-depressants
   Disadvantaged Get < 30 days
• Correlates of < 30 days
  –   Younger
  –   Male
  –   Lower income
  –   Less than high school education
  –   Less satisfied can get health care
  –   Uninsured
  –   Non-Medicare
  –   If privately insured, drug coverage
  –   Type of drug
• Most important predictors in regressions:
  – Lower income & type of drug
Higher Expenditures if < 30 Days
 – Higher expenditures for patients (p<.001)
   • 50% higher out-of-pocket costs
 – Higher expenditures for insurers (p<.001)
   • Although does not include rebates, etc.
• Majority of individuals taking chronic
  medications obtained <30-day supplies
  – Little change between 1996 and 2000
• Disadvantaged individuals more likely to get
  <30-days supplies
• Expenditures for <30-day supplies were
  higher than > 30-day supplies
So Now What?
  Moving the Agenda Forward

• Urgent need for further research:
  – Dispensing patterns
  – Alternatives (e.g., mail order)
  – Impact of dispensing patterns on
    costs and outcomes
        Policy Issues
(AKA more work for researchers!)
 • New Medicare prescription drug benefit
   allows community pharmacies to dispense
   90-day supplies
 • Increasing employer & insurers mandates to
   use mail order services
 • Understanding the impact on costs &
                (but need data)
In God We Trust, All Others
        Bring Data
        Joe Newhouse

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