International Comparison of Out-of-Pocket Costs and Medication Compliance
- Presenter:
Chair: Richard Scheffler; Discussant: Jean Mitchell Tue June 6, 2006 10:45-12:15 Room 235
Background: Pharmaceutical spending has contributed disproportionately to increases in health care spending, causing drug costs to become a prominent health policy issue. Many studies have attempted to quantify cross-national drug price differences. This literature has focused on the full price of pharmaceuticals, regardless of who pays for the drug. However, across countries, and across patients within a country, the burden of these prices falls to differing extents on government health insurance systems, private insurers, and patients themselves. While variation in the full price of drugs across countries has policy implications for total health care expenditures, variation in OOP costs is more salient to clinical issues such as therapy adherence and patient outcomes. Little is known about differences across countries in the out-of-pocket (OOP) costs faced by patients.
Objective: The ability to study international variation in OOP costs and its effects on compliance has been hampered by the lack of comparable data from different countries. This paper analyzes a unique international survey that overcomes this limitation.
Data and Methods: The Dialysis Outcomes and Practice Patterns Study includes 10,398 randomly selected hemodialysis patients from 12 countries (US, Japan, Australia, New Zealand, Belgium, Canada, France, Germany, Italy, Spain, Sweden, and UK). Focusing on one illness and mode of treatment creates a more clinically homogeneous population across countries than would be the case with a more general survey. We compare rates across countries of patient-reported OOP costs for medication and non-purchase of medications due to cost. Logistic regression models identify characteristics associated with positive OOP costs and not purchasing medications due to cost.
Results: The proportion of patients paying OOP costs varies from 29% in France to 99% in Australia. The proportion of patients reporting non-purchase due to cost varies from 3.1% in Japan to 28.6% in the US. Japanese and Swedish patients were less likely to skip medications, and German patients were more likely to skip medications, than would be expected on the basis of costs, indicating that cultural factors or other aspects of the health care system influence cost-related compliance. The odds of paying positive OOP costs increased with income, education, private insurance, and membership in their country’s ethnic majority. Relative to Europe, the odds of facing OOP costs were higher in the US and Canada, and lower in Japan. The odds of cost-related non-purchase were higher for those who faced OOP costs, whose OOP costs exceeded their country’s average, had lower incomes, were younger, unemployed, and members of ethnic minorities. Relative to Europe, non-purchase was less likely in Japan and more likely in the US.
Conclusions: Substantial variation exists across countries in OOP costs and cost-related non-purchase of prescriptions. Few studies have considered the factors that modify patients’ adherence choices in response to medication cost pressures, leaving clinicians with few clues for how to support patients’ medication adherence given the costs that they will incur. The current study represents a significant advance by taking advantage of the variation in cost-sharing and other influences on patients’ medication use across 12 counties.
