Effect of Increased Copayments on Pharmacy Use in the Department of Veterans Affairs Kevin T. Stroupe, PhD 1,2,3,4 1 Midwest Center for Health Services.

Effect of Increased Copayments Effect of Increased Copayments on Pharmacy Use in the on Pharmacy Use in the

Department of Veterans AffairsDepartment of Veterans Affairs

Kevin T. Stroupe, PhDKevin T. Stroupe, PhD1,2,3,41,2,3,4

1 1 Midwest Center for Health Services & Policy Research, Hines VA Hospital, Hines, ILMidwest Center for Health Services & Policy Research, Hines VA Hospital, Hines, IL2 2 Cooperative Studies Program Coordinating Center, Hines VA Hospital, Hines, ILCooperative Studies Program Coordinating Center, Hines VA Hospital, Hines, IL33 VA Information Resource Center, Hines VA Hospital, Hines, IL VA Information Resource Center, Hines VA Hospital, Hines, IL44 Northwestern University Feinberg School of Medicine, Chicago, IL Northwestern University Feinberg School of Medicine, Chicago, IL

CollaboratorsCollaboratorsBridget M. Smith, PhDBridget M. Smith, PhD11 Todd A. Lee, PharmD, PhDTodd A. Lee, PharmD, PhD1,31,3

Ramon Durazo-Arvizu, PhDRamon Durazo-Arvizu, PhD11

Elizabeth Tarlov, PhDElizabeth Tarlov, PhD1,41,4

Lishan Cao, MSLishan Cao, MS33

Zhiping Huo, MSZhiping Huo, MS33

Tammy Barnett, MATammy Barnett, MA1,21,2

Denise Hynes, PhD, RNDenise Hynes, PhD, RN1,41,4

Kevin Weiss, MDKevin Weiss, MD1,31,3

1 1 Midwest Center for Health Services & Policy Research, Hines, ILMidwest Center for Health Services & Policy Research, Hines, IL22 Cooperative Studies Program Coordinating Center, Hines, IL Cooperative Studies Program Coordinating Center, Hines, IL33 Northwestern University Feinberg School of Medicine, Chicago, IL Northwestern University Feinberg School of Medicine, Chicago, IL4 4 VA Information Resource Center, Hines, ILVA Information Resource Center, Hines, IL

BackgroundBackground

In 2001, VA spent over $3 billion on In 2001, VA spent over $3 billion on outpatient medicationsoutpatient medications

As in the private sector, the VA has As in the private sector, the VA has increased cost sharing by patients increased cost sharing by patients

BackgroundBackground

February 4, 2002 VA raised the February 4, 2002 VA raised the medication copayment from $2 to $7 medication copayment from $2 to $7 per 30-day supply per 30-day supply

This increase was the first change in the This increase was the first change in the copayment amount for medications copayment amount for medications since the copayment was instituted in since the copayment was instituted in 1990 1990

Study ObjectivesStudy Objectives To examine the association of the copayment To examine the association of the copayment

increase with medication acquisition from VA increase with medication acquisition from VA pharmaciespharmacies– For all chronic medicationsFor all chronic medications– For specific categories of medicationsFor specific categories of medications

To examine the association of the copayment To examine the association of the copayment increase with medication acquisition for higher increase with medication acquisition for higher and lower pharmacy usersand lower pharmacy users

Study ObjectivesStudy Objectives To examine rates of discontinuation of VA To examine rates of discontinuation of VA

pharmacy usepharmacy use– For all chronic medications, over-the-counter For all chronic medications, over-the-counter

(OTC) medications, and prescription only (OTC) medications, and prescription only medications medications

– For medications to treat common chronic conditionsFor medications to treat common chronic conditions

Setting:Setting:Medication Copayments in VAMedication Copayments in VA

Veterans may obtain both Rx-only medications Veterans may obtain both Rx-only medications and OTC medications from VA pharmaciesand OTC medications from VA pharmacies– All medications require a prescription from VAAll medications require a prescription from VA– The same copayment applies to Rx-only and OTC The same copayment applies to Rx-only and OTC

medicationsmedications

Veterans are not subject to copayments for Veterans are not subject to copayments for supplies (e.g., gauze) from the VA pharmacysupplies (e.g., gauze) from the VA pharmacy


Veterans are subject to the copayment Veterans are subject to the copayment depending on their VA Priority category depending on their VA Priority category (1 though 8), (1 though 8),

– which were established to manage access to VA which were established to manage access to VA care in relation to VA’s resourcescare in relation to VA’s resources


Veterans in Priority 1 Veterans in Priority 1

– have a service-connected condition that is 50% have a service-connected condition that is 50% or more disabling or more disabling

– are exempt from drug copaymentsare exempt from drug copayments


Veterans in Priorities 2 through 6 Veterans in Priorities 2 through 6

– have service-connected conditions <50% disabling, have service-connected conditions <50% disabling, low incomes, or other recognized statuses (e.g., low incomes, or other recognized statuses (e.g., former POW)former POW)

– are exempt from copayments for drugs for their are exempt from copayments for drugs for their service-connected disabilitiesservice-connected disabilities

– have a cap on their out-of-pocket medication have a cap on their out-of-pocket medication spending set at $840spending set at $840 annually (increased to $960 annually (increased to $960 in 2006)in 2006)


Veterans in Priorities 7 and 8 Veterans in Priorities 7 and 8

– are subject to copayments for all drugsare subject to copayments for all drugs

– have no cap on their annual out-of-pocket have no cap on their annual out-of-pocket prescription copayments prescription copayments

Setting:Setting:Medication Copayments in VAMedication Copayments in VAVeterans may have copayments for Veterans may have copayments for

No Drugs No Drugs

– Priority Category 1Priority Category 1

Some Drugs Some Drugs

– Priority Categories 2 - 6 Priority Categories 2 - 6

All DrugsAll Drugs

– Priority Categories 7 - 8Priority Categories 7 - 8

Study DesignStudy Design Retrospective observational study using Retrospective observational study using

data from national VA databases data from national VA databases

We examined medication acquisition of We examined medication acquisition of patients from VA in the 1-year periodspatients from VA in the 1-year periods

– before (February 4, 2001 to February 3, 2002) before (February 4, 2001 to February 3, 2002) and and

– after (February 4, 2002 to February 4, 2003) after (February 4, 2002 to February 4, 2003) the copayment increase the copayment increase

Study SampleStudy Sample 5% random sample of male VA users in 5% random sample of male VA users in

fiscal year (FY) 2001fiscal year (FY) 2001

To ensure that differences in medication To ensure that differences in medication acquisition before and after the copayment acquisition before and after the copayment increase were not due to length of time in increase were not due to length of time in the study, we restricted sample tothe study, we restricted sample to

– veterans who used VA inpatient or outpatient veterans who used VA inpatient or outpatient services in the 1-year period before the study services in the 1-year period before the study

– veterans who were alive at the end of the study veterans who were alive at the end of the study period period

Study TimelineStudy Timeline

BeforeBeforeStudyStudy

PrePrePeriodPeriod

PostPostPeriodPeriod

Copayment ChangeCopayment Change

Febr

uary

4, 20

02

Febr

uary

4, 20

02

Study PeriodStudy Period

Febr

uary

4, 20

03

Febr

uary

4, 20

03

Febr

uary

4, 20

01

Febr

uary

4, 20

00

Febr

uary

4, 20

00

Study SampleStudy Sample~4 million VA users in fiscal year ~4 million VA users in fiscal year

20012001

5% random sample of 5% random sample of male VA usersmale VA users

207,298207,298

Male veterans in study Male veterans in study cohort 149,010cohort 149,010

Eliminated:Eliminated:

• 2,075 who died before study period2,075 who died before study period

• 7,318 non-veterans7,318 non-veterans

• 36,062 with no VA use before study 36,062 with no VA use before study periodperiod

• 10,384 who died during study period10,384 who died during study period

• 2,449 with missing data2,449 with missing data

Copays forCopays forNo Drugs No Drugs (Priority 1)(Priority 1)

19,494 (13%)19,494 (13%)

Copays for Copays for Some DrugsSome Drugs

(Priority 2 – 6)(Priority 2 – 6)101,331 (68%)101,331 (68%)

Copays for Copays for All DrugsAll Drugs

(Priority 7 – 8)(Priority 7 – 8)28,185 (19%)28,185 (19%)

Data Sources for StudyData Sources for Study VA Pharmacy Benefit Management (PBM) VA Pharmacy Benefit Management (PBM)

DatabaseDatabase

– Used to obtain: Medication acquisition 1 year before Used to obtain: Medication acquisition 1 year before and after copayment increase (Feb 4, 2001 – Feb 4, and after copayment increase (Feb 4, 2001 – Feb 4, 2003)2003)

VA National Patient Care Database (NPCD) VA National Patient Care Database (NPCD) Medical SAS DatasetsMedical SAS Datasets

– Used to obtain: Patient characteristics Used to obtain: Patient characteristics

e.g., age, race, etc.e.g., age, race, etc.

VA Enrollment fileVA Enrollment file

– Used to obtain: Veteran priority categoryUsed to obtain: Veteran priority category

Pharmacy UtilizationPharmacy Utilization VA copayment applies to each 30-day supply VA copayment applies to each 30-day supply

or lessor less

We calculated the number of 30-day We calculated the number of 30-day equivalent supplies by dividing the day’s equivalent supplies by dividing the day’s supply as dispensed by 30 supply as dispensed by 30

– e.g., one prescription with an 90-day supply e.g., one prescription with an 90-day supply dispensed became three 30-day equivalent dispensed became three 30-day equivalent suppliessupplies

We considered a prescription with <30-day We considered a prescription with <30-day supply as one 30-day supply because the full supply as one 30-day supply because the full copayment applies to these prescriptions copayment applies to these prescriptions

Pharmacy UtilizationPharmacy Utilization Patients may obtain drugs from VA to treat Patients may obtain drugs from VA to treat

chronic conditions (e.g., hypertension) or for chronic conditions (e.g., hypertension) or for short-term conditions (e.g., infections)short-term conditions (e.g., infections)

Because changes in acquisition of drugs for Because changes in acquisition of drugs for chronic conditions could affect the long-term chronic conditions could affect the long-term management and consequences of these management and consequences of these conditions, conditions,

– we focused on drugs for chronic rather than acute we focused on drugs for chronic rather than acute conditionsconditions

Pharmacy UtilizationPharmacy Utilization To exclude medications that were likely to be To exclude medications that were likely to be

used on a short-term basisused on a short-term basis

– we removed any type of drug that the patient did we removed any type of drug that the patient did not receive at least one 30-day supply before or not receive at least one 30-day supply before or after the copayment increase after the copayment increase

Pharmacy Use CategoriesPharmacy Use Categories

We divided patients into higher and lower We divided patients into higher and lower pharmacy use groups based on the number of pharmacy use groups based on the number of different medications patients received before different medications patients received before the copayment increasethe copayment increase

Pharmacy Use CategoriesPharmacy Use Categories

Based on quartiles of the number different Based on quartiles of the number different medications, we grouped patients as medications, we grouped patients as

– low medication users (≤ 3 medications)low medication users (≤ 3 medications)

– moderately low users (4 – 6 medications),moderately low users (4 – 6 medications),

– moderately high users (7 – 11 medications)moderately high users (7 – 11 medications)

– and high users (> 11 medications)and high users (> 11 medications)

Medication CategoriesMedication Categories

All chronic medications: All chronic medications:

– Medications with al least one 30-day supplyMedications with al least one 30-day supply

Medication CategoriesMedication Categories Higher and lower-cost medications Higher and lower-cost medications

– medications with a retail cost more or less than the medications with a retail cost more or less than the copaymentcopayment

– Based on adjusted Average Wholesale Price Based on adjusted Average Wholesale Price

OTC and Rx-only medicationsOTC and Rx-only medications

– Based on indicator variables in the databaseBased on indicator variables in the database

Medication CategoriesMedication Categories More and less essential medicationsMore and less essential medications

– Medications that prevented deterioration in health, Medications that prevented deterioration in health, prolonged life, and were not likely to be prescribed prolonged life, and were not likely to be prescribed without a definitive diagnosis without a definitive diagnosis

– Medications were that could relieve symptoms Medications were that could relieve symptoms without affecting the underlying disease process without affecting the underlying disease process

– Based on modified lists from WHO that have been Based on modified lists from WHO that have been used in previous studiesused in previous studies

Medication CategoriesMedication Categories Medications for chronic conditionsMedications for chronic conditions

– These medications included: anti-hypertensives, These medications included: anti-hypertensives, lipid lowering agents, anti-coagulants, diabetes lipid lowering agents, anti-coagulants, diabetes medications, antiarrhythmics, antianginals, medications, antiarrhythmics, antianginals, antidepressants, and antipsychotics antidepressants, and antipsychotics

– To ensure that antidepressant users were not To ensure that antidepressant users were not receiving them on only a short-term basis, we receiving them on only a short-term basis, we restricted antidepressant users torestricted antidepressant users to

» Patients with Dx of depression during the 2 years prior to Patients with Dx of depression during the 2 years prior to the copayment increase the copayment increase

» Who were using an antidepressant at the beginning of the Who were using an antidepressant at the beginning of the study period study period

AnalysisAnalysis

To examine the effect of the copayment To examine the effect of the copayment on the number of 30-day supplies in the on the number of 30-day supplies in the 1-year periods before and after the 1-year periods before and after the copayment increase copayment increase – We used zero-inflated negative binomial We used zero-inflated negative binomial

count models count models – controlling for age, race, comorbidities, controlling for age, race, comorbidities,

insurance status, distance, and socio-insurance status, distance, and socio-economic statuseconomic status

AnalysisAnalysis

To determine the impact of the copayment To determine the impact of the copayment increase on medication acquisition from the increase on medication acquisition from the VA,VA,– we used the natural experiment that occurred we used the natural experiment that occurred

when the copayment was increased for certain when the copayment was increased for certain veterans veterans

Veterans with no copays were ‘control’ Veterans with no copays were ‘control’ groupgroup

Veterans with copays for some or all Veterans with copays for some or all medications were ‘experimental’ groups medications were ‘experimental’ groups

AnalysisAnalysis

We used a difference-in-differences We used a difference-in-differences approach toapproach to– estimate the change in number of 30-day estimate the change in number of 30-day

supplies after the increase for veterans supplies after the increase for veterans subject to the copayment relative tosubject to the copayment relative to

– the change in number of 30-day supplies the change in number of 30-day supplies after the increase for veterans with no after the increase for veterans with no copaymentscopayments

AnalysisAnalysis Advantage of difference-in-differences Advantage of difference-in-differences

method:method:– any change in control group’s medication any change in control group’s medication

acquisition reflects changes unrelated to the acquisition reflects changes unrelated to the copayment copayment

– while any change in the experimental groups’ while any change in the experimental groups’ medication acquisitions reflects both the (same) medication acquisitions reflects both the (same) naturally occurring change plus the impact of naturally occurring change plus the impact of the copayment change the copayment change

AnalysisAnalysis To implement the difference-in-differences estimator, we To implement the difference-in-differences estimator, we

specified the conditional mean number of 30-day specified the conditional mean number of 30-day prescriptions from VA as prescriptions from VA as

E(E(yyitit||xxitit) = (1-) = (1-qqitit) exp(β) exp(β00 + β+ β11Some_copaySome_copayitit + β + β22All_copayAll_copayitit + β + β33PostPostt t

+ β+ β44[[Some_copaySome_copayitit PostPosttt] + β] + β55 [ [All_copayAll_copayitit PostPosttt] + ] + ′′zzitit))

Where: Where: Some_copaySome_copayitit is an indicator that patient is an indicator that patient ii was subject to was subject to the copayment for some medications in period the copayment for some medications in period

tt, , All_copayAll_copayitit is an indicator that the patient was subject to the is an indicator that the patient was subject to the

copayment for all medications, copayment for all medications, PostPosttt is an indicator whether the copayment increase was is an indicator whether the copayment increase was

applicable in period applicable in period tt, , Some_copaySome_copayitit PostPosttt and and All_copay All_copayitit PostPosttt indicate indicate

patients subject to the copayment after the patients subject to the copayment after the copayment increasecopayment increase

zzitit are other patient characteristics are other patient characteristics

AnalysisAnalysis To examine the impact of copay increase on To examine the impact of copay increase on

discontinuation of VA pharmacy services (for discontinuation of VA pharmacy services (for all chronic medications, Rx-only all chronic medications, Rx-only medications, OTC medications, and medications, OTC medications, and medications for specific conditions), medications for specific conditions), – we used multivariable logistic regression we used multivariable logistic regression

models to examine the probability of models to examine the probability of discontinuing VA pharmacy use for medications discontinuing VA pharmacy use for medications after the copayment increaseafter the copayment increase

For all models, the veterans with no For all models, the veterans with no medication copayments were the reference medication copayments were the reference group group

AnalysisAnalysis

For each logistic regression model, we For each logistic regression model, we included only patients who had a included only patients who had a prescription for the type of medication being prescription for the type of medication being examinedexamined

Patient Characteristics by Patient Characteristics by Copay CategoryCopay Category

Copays forCopays for

No DrugsNo Drugs

N = 19,620N = 19,620

Copays for Copays for Some Drugs Some Drugs

N = 102,643N = 102,643

Copays for Copays for All DrugsAll Drugs

N = 28,720N = 28,720

Age, mean Age, mean SD, years SD, years 59 59 14 14 61 61 14 14 66 66 12 12

Black, %Black, % 1313 1414 55

Married, %Married, % 6262 5050 7070

Distance to closest VA,Distance to closest VA,

mean mean SD, miles SD, miles46 46 104 104 41 41 83 83 42 42 68 68

Hierarchical Condition Hierarchical Condition Category, mean Category, mean SD, Score SD, Score 0.90 0.90 0.77 0.77 0.78 0.78 0.70 0.70

0.65 0.65 0.480.48

VA insurance coverage only, %VA insurance coverage only, % 5151 4949 2525

Median Income in Zip CodeMedian Income in Zip Code $40,000$40,000 $45,000$45,000 $48,000$48,000

Monthly 30-Day SuppliesMonthly 30-Day SuppliesAll Chronic DrugsAll Chronic Drugs

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5

5.5

6

6.5

Feb-01

Apr-01

J un-01

Aug-01

Oct-01

Dec-01

Feb-02

Apr-02

J un-02

Aug-02

Oct-02

Dec-02

Feb-03

MONTH

Ave

# o

f R

X

Copaysfor NoDrugs

Copaysfor SomeDrugs

Copaysfor AllDrugs

Copay Increase

Adjusted Change in Number of 30-Day Supplies Adjusted Change in Number of 30-Day Supplies Annually After Copay IncreaseAnnually After Copay Increase

All Chronic DrugsAll Chronic Drugs

Copays for Some DrugsCopays for Some Drugs

N = 102,643N = 102,643Copays for All DrugsCopays for All Drugs

N = 28,720N = 28,720

Mean Mean Number Number of 30-of 30-Day Day

SuppliesSupplies

Change in Change in 30-Day 30-Day SuppliesSupplies

95% 95% CICI

Mean Mean Number Number

of 30-Day of 30-Day SuppliesSupplies

Change in Change in 30-Day 30-Day

Supplies Supplies

95% CI95% CI

All Chronic All Chronic DrugsDrugs

46.946.9 -2.1-2.1 -3.0 to -1.3-3.0 to -1.3 41.241.2 -1.9-1.9 -2.9 to -0.9-2.9 to -0.9

Adjusted Change in Number of 30-Day Supplies Adjusted Change in Number of 30-Day Supplies Annually After Copay Increase Annually After Copay Increase

Copays for Some Copays for Some DrugsDrugs

N = 101,331N = 101,331

Copays for All DrugsCopays for All Drugs

N = 28,185N = 28,185

Mean Mean Number of Number of

30-Day 30-Day SuppliesSupplies

Change Change in 30-in 30-Day Day

SuppliesSupplies

95% 95% CICI

Mean Mean Number Number

of 30-Day of 30-Day SuppliesSupplies

Change in Change in 30-Day 30-Day

Supplies Supplies

95% CI95% CI

Higher costHigher cost 40.0 40.0 -1.6-1.6 -2.3 to --2.3 to -0.90.9

36.336.3 -1.6-1.6 -2.5 to -0.7-2.5 to -0.7

Lower costLower cost 6.16.1 -0.9-0.9 -1.1 to --1.1 to -0.70.7

4.04.0 -1.4-1.4 -1.6 to -1.2-1.6 to -1.2

Rx-onlyRx-only 36.636.6 -0.9-0.9 -1.6 to --1.6 to -0.20.2

34.034.0 -0.6-0.6 -1.5 to 0.2-1.5 to 0.2

OTCOTC 7.57.5 -1.6-1.6 -1.8 to --1.8 to -1.41.4

4.74.7 -2.8-2.8 -3.0 to -2.6-3.0 to -2.6

More More EssentialEssential

21.121.1 -0.9-0.9 -1.3 to --1.3 to -0.40.4

21.121.1 -0.7-0.7 -1.2 to -0.2-1.2 to -0.2

Less Less EssentialEssential

0.60.6 0.020.02 -0.03 to -0.03 to 0.080.08

0.60.6 0.050.05 -0.03 to 0.1-0.03 to 0.1

Percentage Reduction in Annual Number of 30-Percentage Reduction in Annual Number of 30-Day Supplies Following Copay IncreaseDay Supplies Following Copay Increase

-35%

-60%

-4%-2%-4%

-15%

-21%

-4%-2% -3%

-5%-4%

-0.70

-0.60

-0.50

-0.40

-0.30

-0.20

-0.10

0.00

All Chronic Drugs High-cost Low-cost Prescription-only Over-the-counter Essential

Copays for SomeDrugsCopays for All Drugs

Number of 30-Day SuppliesNumber of 30-Day Supplies

Low Medication UsersLow Medication Users

Copay GroupCopay Group BeforeBeforeIncreaseIncrease

AfterAfterIncreaseIncrease

DifferenceDifference P-ValueP-Value

No DrugsNo Drugs(N = 3,855)(N = 3,855)

8.68.6 10.410.4 1.81.8 < 0.001< 0.001

Some DrugsSome Drugs(N = 30,356)(N = 30,356)

7.37.3 7.97.9 0.60.6 < 0.001< 0.001

All DrugsAll Drugs(N = 10,535)(N = 10,535)

8.28.2 8.48.4 0.20.2 0.290.29


Moderately Low Medication UsersModerately Low Medication Users




No DrugsNo Drugs(N = 3,364) (N = 3,364)

33.233.2 38.238.2 5.05.0 < 0.001< 0.001


32.332.3 34.234.2 1.91.9 < 0.001< 0.001


37.437.4 38.238.2 0.80.8 0.0080.008


Moderately High Medication UsersModerately High Medication Users

Copay GroupCopay Group Before Before IncreaseIncrease

After After IncreaseIncrease



61.761.7 66.166.1 4.44.4 < 0.001< 0.001


59.659.6 58.158.1 -1.5-1.5 < 0.001< 0.001


64.664.6 61.061.0 -3.6-3.6 < 0.001< 0.001


High Medication UsersHigh Medication Users





127.1127.1 126.1126.1 -1.0-1.0 0.310.31


113.6113.6 104.2104.2 -9.4-9.4 < 0.001< 0.001


109.0109.0 95.895.8 -13.2-13.2 < 0.001< 0.001

Change in Number of 30-Day Supplies After Change in Number of 30-Day Supplies After Copay By Medication User GroupsCopay By Medication User Groups

1.80.6 0.2

1.90.8

4.4

-1.5

-3.6

-1.0

-9.4

-13.3

5.0

-15.0

-10.0

-5.0

0.0

5.0

10.0 Low Medication Users

Moderately Low Medication UsersModerately High Medication Users

High Medication Users

NS = Not Significant; for all other values P < 0.01

NS

NS

Copays forNo Drugs

Copays forSome Drugs

Copays forAll Drugs

Percent of Patients Discontinuing VA Percent of Patients Discontinuing VA Pharmacy After Copay Increase Pharmacy After Copay Increase

4% 4%

14%9% 9%

28%

9% 9%

41%

0%

10%

20%

30%

40%

50%

All ChronicDrugs

Rx-only OTC

No Copays

Copays forSome DrugsCopays for AllDrugs

* * * *

*

*

* P < 0.001

Percent of Patients Discontinuing VA Percent of Patients Discontinuing VA Pharmacy After Copay Increase Pharmacy After Copay Increase

9%

6%

15%

17%

21%

12%

8%9%

10%

7%

16%

19%

27%

23%

15%

9% 9%8%

15%

18%

29%

16%

6%

30%

0%

10%

20%

30%

HTN LipidLoweringAgents

Diabetes Anti-arrythmia

Anti-coag. Angina Anti-psych. Anti-depressants

No Copays

Copays for SomeDrugs

Copays for All Drugs

*

* **

*

*

**

*

**

* P < 0.001

Discontinuation of VA Pharmacy UseDiscontinuation of VA Pharmacy Use

Odds Ratios from Logistic Regression AnalysesOdds Ratios from Logistic Regression Analyses

Copay GroupCopay Group Copay for Copay for Some Some

MedicationsMedications

95% CI95% CI Copay for Copay for AllAll

MedicatioMedicationsns

95% CI95% CI

All Chronic All Chronic DrugsDrugs

2.18* 2.18* 2.01 to 2.35 2.01 to 2.35 2.43*2.43* 2.22 to 2.65 2.22 to 2.65

Rx-only DrugsRx-only Drugs 2.18*2.18* 2.02 to 2.36 2.02 to 2.36 2.37*2.37* 2.17 to 2.59 2.17 to 2.59

OTC DrugsOTC Drugs 2.44*2.44* 2.32 to 2.57 2.32 to 2.57 3.97*3.97* 3.74 to 4.21 3.74 to 4.21

* P < 0.001







95% CI95% CI

Hypertension DrugsHypertension Drugs

(n=104,372)(n=104,372)

1.34*1.34*

1.23 to 1.461.23 to 1.46 1.26*1.26* 1.14 to 1.391.14 to 1.39

Lipid Lowering Lipid Lowering Drugs (n=60,720)Drugs (n=60,720)

1.19*1.19*

1.09 to 1.311.09 to 1.31 0.970.97 0.87 to 1.080.87 to 1.08

Diabetes Drugs Diabetes Drugs (n=30,407)(n=30,407)

0.970.97 0.82 to 1.15 0.82 to 1.15 0.940.94 0.78 to 1.140.78 to 1.14

Anti-coagulant Anti-coagulant Drugs (n=14,948)Drugs (n=14,948)

1.061.06 0.92 to 1.220.92 to 1.22 0.990.99 0.85 to 1.170.85 to 1.17

* P < 0.001







95% CI95% CI

Angina Drugs Angina Drugs (n=22,614)(n=22,614)

1.38*1.38* 1.25 to 1.521.25 to 1.52 1.58*1.58* 1.40 to 1.781.40 to 1.78

Antiarrythmics Antiarrythmics (n=11,335)(n=11,335)

0.990.99 0.83 to 1.180.83 to 1.18 0.910.91 0.74 to 1.110.74 to 1.11

Antipsychotics Antipsychotics (n=9,174)(n=9,174)

2.11*2.11* 1.87 to 2.391.87 to 2.39 2.39*2.39* 1.88 to 3.051.88 to 3.05

Antidepressants Antidepressants (n=9,935)(n=9,935)

1.89*1.89* 1.60 to 2.251.60 to 2.25 1.90*1.90*

1.46 to 2.481.46 to 2.48

* P < 0.001

ConclusionsConclusions For veterans subject to the copayment, the For veterans subject to the copayment, the

number of 30-day supplies from VA fell number of 30-day supplies from VA fell following the copayment increase following the copayment increase

The copayment increase had a larger effect The copayment increase had a larger effect as the number of different drugs that as the number of different drugs that patients received increasedpatients received increased

E.g., for high medication users with copays E.g., for high medication users with copays for all drugsfor all drugs

–Copays increased > 300% annually Copays increased > 300% annually ($218 to $670) ($218 to $670) –Drug acquisition decreased 12%Drug acquisition decreased 12%

ConclusionsConclusions Longer-term follow-up is needed to Longer-term follow-up is needed to

determine if the decrease in drug acquisition determine if the decrease in drug acquisition of moderately high or high medication users of moderately high or high medication users had adverse health effectshad adverse health effects

ConclusionsConclusions The copay increase had a relatively larger The copay increase had a relatively larger

effect on acquisition of lower cost and OTC effect on acquisition of lower cost and OTC medicationsmedications

Charging veterans copayments for some Charging veterans copayments for some drugs that is larger than they might pay drugs that is larger than they might pay elsewhere might lead veterans to obtain elsewhere might lead veterans to obtain drugs from multiple pharmacies, limiting drugs from multiple pharmacies, limiting VA’s ability to monitor for drug-drug VA’s ability to monitor for drug-drug interactions or discontinuationinteractions or discontinuation

ConclusionsConclusions The copayment increase had a significant The copayment increase had a significant

effect on the probability of discontinuing VA effect on the probability of discontinuing VA pharmacy use for all chronic medications, pharmacy use for all chronic medications, Rx-only and OTC medications, and for Rx-only and OTC medications, and for medications to treat chronic conditions medications to treat chronic conditions including hypertension and depressionincluding hypertension and depression

If these medications are not obtained If these medications are not obtained elsewhere there could be unintended elsewhere there could be unintended consequences on health outcomes and consequences on health outcomes and overall health care costs overall health care costs

Effect of Increased Copayments on Pharmacy Use in the Department of Veterans Affairs Kevin T. Stroupe, PhD 1,2,3,4 1 Midwest Center for Health Services.

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