Utilization of essential medications by vulnerable older people after a drug benefit cap: importance of mental disorders, chronic pain, and practice setting.
OBJECTIVE
To identify specific characteristics of patients, physicians, and treatment settings associated with decreased receipt of essential medications in a chronically ill, older population following a Medicaid three-prescription monthly reimbursement limit (cap).


METHODS
Quasi-experiment with bivariate and multivariate regression.


METHODS
Patients in the New Hampshire Medicaid program and their regular prescribing physicians.


METHODS
Three hundred and forty-three chronically ill Medicaid enrollees with regular use of essential medications for heart disease, asthma/chronic obstructive pulmonary disease, diabetes mellitus, seizure, or coagulation disorders who received an average of three or more prescriptions per month during the baseline year.


METHODS
Postcap patient-level change in standard monthly dose of essential medications compared with the baseline period, presence of 11 comorbidities (defined by regular use of specific indicator drugs), practice setting, and location of regular prescribing physician.


RESULTS
The mean percentage change in standard doses of essential medications following the cap was -34.4%. Larger changes were significantly associated with several baseline measures: greater numbers of precap medications, greater numbers of comorbidities, longer hospitalizations, and greater use of ambulatory services. The three comorbidities associated with the largest relative reduction in essential drug use were psychoses/bipolar disorders, anxiety/sleep problems, and chronic pain. Patients of physicians in group practices, clinics, or hospitals tended to have smaller dose reductions than those whose physicians were in solo or small-group practice.


CONCLUSIONS
Patients most at risk of reduced access to essential medications because of a reimbursement cap include those with multiple chronic illnesses requiring drug therapy, especially illnesses with a mental health component. Physicians in clinics or large group practices may have maintained patient medication regimens more effectively.
Fortess
E E
EE
Department of Public Management/Health Administration Concentration, Frank Sawyer School of Management, Suffolk University, Drug Policy Research Group, Boston, Massachusetts, USA.
Soumerai
S B
SB
McLaughlin
T J
TJ
Ross-Degnan
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D
D000368:Aged; D000369:Aged, 80 and over; D002908:Chronic Disease / Q000188:drug therapy* / Q000453:epidemiology; D015897:Comorbidity; D003363:Cost Control; D011307:Drug Prescriptions / Q000191:economics* / Q000706:statistics & numerical data; D004363:Drug Utilization / Q000191:economics* / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data*; D018954:Drugs, Essential / Q000191:economics* / Q000627:therapeutic use*; D005260:Female; D016330:Frail Elderly / Q000706:statistics & numerical data; D006302:Health Services Research; D006801:Humans; D008297:Male; D008484:Medicaid / Q000191:economics / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data; D001523:Mental Disorders / Q000188:drug therapy* / Q000453:epidemiology; D008875:Middle Aged; D015999:Multivariate Analysis; D009513:New Hampshire / Q000453:epidemiology; D010146:Pain / Q000188:drug therapy* / Q000453:epidemiology; D010818:Practice Patterns, Physicians' / Q000191:economics / Q000331:legislation & jurisprudence / Q000706:statistics & numerical data; D011237:Predictive Value of Tests; D012044:Regression Analysis; D012051:Reimbursement Mechanisms / Q000191:economics / Q000331:legislation & jurisprudence* / Q000706:statistics & numerical data
D018954:Drugs, Essential