1. 1 The effect of drug co-payment policy on the purchase of prescription drugs for children with infections in the community Haim Reuveni, MD Health Policy 62 (2002) 1–13 Department of Health Policy and Management, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel First Study

2. 2 Introduction Co-payment (CP) policy - patients cover part of treatment cost CP policy reduces expenditures of the insurance carrier and unnecessary use of services CP reduce consumption of the medical care, prescribed drugs mainly among low SES people CP cause deterioration in health state. Each 10% increase in CP is associated with an 8.7% decrease in total per-episode expenditure

3. 3 Aims To examine the effect CP on the purchase of prescribe drugs in children with acute infectious diseases. This was preformed in community settings (Pediatric Health Center in the city of Kiryat-Gat)

4. 4 Objectives 1.To calculate the rates of partial or non-purchase of antibiotics (WHO classification). 2.To assess the association between the number & cost of prescribe drugs and the non or partial purchase of the drugs. 3.To identify factors that can predict non or partial purchase of prescribe drugs due to cost considerations.

5. 5 Methods Design: Cross-sectional study. Setting: The Pediatric Health Center in the city of Kiryat-Gat one of Israel’s poorest cities (high unemployment rate). The pediatric clinic has: a registry of 6500 children an average of 200 visits per day. 5 pediatricians. Data collection was for 6-weeks in May to June 1999.

6. 6 Study population Included: Children and adolescents aged 0–18 years, diagnosed by a pediatrician with an acute infectious disease for which drugs, including antibiotics, were prescribed. Excluded: children and adolescents that: (1) already taking antibiotic drugs (2) diagnosed for an acute infectious disease, but did not receive a prescription (3) received a prescription which did not include antibiotics.

7. 7 Data sources 1)The computerized patient visit reports (I.e. demographics, type of drug, dosage, date of prescription). 2) The computerized drug dispensing reports from the clinic’s pharmacy.

8. 8 Three study groups were defined: Full purchase- All drugs prescribed were issued by the pharmacy. Partial purchase- Some of the drugs and/or amounts were issued. Non-purchase- None of the prescribed drugs were issued within 7 days of prescription date.

9. 9 Study protocol

10. 10 Results During the 6-week study period, antibiotics were prescribed for the following acute infections

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14. 14 Conclusions: CP is a serious barrier for purchasing the prescribed medication for children with acute infections. The policy has a particularly deleterious effect in under-privileged populations. CP policy is in contradiction with the proclaimed principles of justice and equality underlying the obligatory Israeli National Health Insurance Law.

15. 15 The incomplete purchase (partial treatment) of antibiotics may: lead to an extended period of symptoms. Development of long-term complications such as meningitis and rheumatic fever. The role of partial antibiotic treatment in the development of antibiotic resistance is not clear.

16. 16 More questions……. What are the drug purchasing patterns when several family members are concurrently ill. What is the long-term clinical outcome for these children? What is the consequent extent of medical care utilization by these children? How can we define a “reasonable level ” of CP ? for essential drugs or other treatments…….. Zero CP? for different layers of income……….. Partial/Full CP? Further studies are required……….

17. 17 More research

18. 18 Isr Med Assoc J. 2005 Jan;7(1):13-8. Determinants affecting initiation of continuous positive airway pressure treatment. Brin YSBrin YS, Reuveni H, Greenberg S, Tal A, Tarasiuk A.Reuveni HGreenberg STal ATarasiuk A 2 nd Study

19. 19 Purchasing Declined PurchasedDeclined AcceptanceDeclinedOSAS (-) OSAS (+) PSG studyDiagnosisTitration study CPAP adaptation Adaptation (N=324, 81%) (N=183, 46%) (N=128, 32%) (N=400, 100%) (N=76, 19%)(N=141, 35%)(N=55, 14%)

20. 20 Number of Patients (%) Monthly income Brin et al Figure 2

21. 21 The effects of co-payment policy on compliance with medical technologies: The case of chronic CPAP treatment in patients with OSAS requiring continuous positive airway pressure (CPAP) therapy Haim Reuveni 1, Ariel Tarasiuk 2 Supported by Grant from the Israeli Institute for Health Policy and Health Services Research, award no. A/147/2003. 3 d Study

22. 22 Introduction CPAP device is provided free of charge in countries such as Germany, the United Kingdom, several parts of Canada and by some health care providers in the USA. In these countries, treatment initiation and long-term compliance were found to be more than 70%. In Israel, results strongly suggest that sharing the cost of CPAP is a potential barrier to purchase CPAP.

23. 23 Main Objective To develop a model for decision-makers to determine CP policy for CPAP

24. 24 Specifically 1) To compare compliance rates according to CP policy with that of other industrialized countries 2) To determine the cost-effectiveness of CPAP therapy. 3) To compare compliance rate to CPAP before (full CP) and after change (partial CP) in CP policy.

25. 25 Group 1- Declining CPAP. 1a- CPAP will be re- offered CPAP with partial CP. 1b- CPAP will not re-offered Group 2- Commencing CPAP. Group 3- New patients, minimal CP. followed-up for 12 m

26. 26 LOW SOCIOECONOMIC STATUS IS A RISK FACTOR FOR CPAP ACCEPTANCE AMONG ADULT OSAS PATIENTS REQUIRING TREATMENT Submitted for publication Tzahit Simon-Tuval, Haim Reuveni, Sari Greenberg, Arie Oksenberg, Asher Tal, Ariel Tarasiuk

27. 27 PSG study (n=278) Not requiring CPAP treatment (n=116) Decline CPAP treatment (n=97, 60%) Requiring CPAP treatment (n=162) Commence CPAP treatment (n=65, 40%)

28. 28 Patients Recruitment PSG study CPAP Titration CPAP Adaptation AcceptingDeclining Questioner 2 Questioner 1 Patient decision Conclusion of Adaptation

29. 29 pvalue OSA patients requiring CPAP OSA patients not requiring CPAP 162116n 0.00174.755.2Males (%) 0.000754.9±12.049.7±13.2Age (years) 0.0132.3±5.430.3±7.3BMI (kg/m 2 ) <0.000158.0237.9%37.9% HTN and/or CVD (prevalence) 0.56231.8%30.4%LowIncome 43.1%49.1%Average 25.2%20.5%High Characteristics of OSAS Patients

30. 30 Reasons for purchasing CPAP CPAPpurchasing % patients (n=60) Reasons for purchasing CPAP device 78%It solved my snoring problems 78%It reduced by daytime sleepiness 59%It improved my Sleep 53%My physician and sleep laboratory team to convinced me 53%Encouragement from partner 35%Will improve my associated morbidity 33%This is the best treatment available for me

31. 31 Reasons for declining CPAP CPAPDeclining % patients (n=102) % patients (n=102) Reasons for Declining CPAP device 38%I tried and could not adapt 31% I am Interested in other treatments 29% CPAP cost is too expensive 28% I have side effects 13%I feel better and don’t need this treatment 10%Not encouraged by my partner 6%Not encouraged by my physician

32. 32 Determinants of OSAS Patients Requiring and Accepting CPAP Treatment (n=162) Multivariate analysis Univariate analysis Variable 95% CIOR95% CIOR 1.2-4.62.41.3-3.22.03Income (low, medium, high) 1.01-1.11.071.02-1.11.05Age (year +1) 0.9-1.10.980.96-1.11.02BMI (+1 Kg/m 2 ) 1.4-12.04.21.54-5.73.0AHI (≥35 vs. <35 events/hr) 0.3-2.30.90.35-1.30.66ESS (≥10 vs. <10 score) 1.4-13.34.31.1-5.12.4Partner sleeps separately (yes vs. no) 1.1-7.52.91.1-5.42.5 Family and/or friends experience with CPAP (yes vs. no) Income – individual income level; BMI body mass index; AHI – Apnea-Hypopnea Index; ESS – Epworth Sleepiness Scale score; CVD – Cardiovascular Disease; HTN – Hypertension; Area under the ROC 82% for patients living with partner.

33. 33 Thank You !