Change of pharmaceutical co-payment in spain and inequality

Resumen

ABSTRACT Objectives This thesis has three objectives. First, to test the heterogeneity of the effect on drug consumption of the Spanish 2012 change in pharmaceutical cost-sharing by therapeutic groups in the Canary Islands (chapter 1). Second, to assess the heterogeneous effect of the reform on drug consumption by age groups (chapter 2). And third, to analyse both the distributive consequences of the reform and the distributive effects of twelve other simulated, alternative co-payment schemes, including a recent reform of the Canary Islands Government whereby low-income pensioners are provided with free full coverage (chapter 3). Method Random sample (provided by the Canary Islands Health Service) of around 42,000 people covered by the Spanish National Health Service (SNHS). The database includes individualised monthly-dispensed medications (prescribed by the SNHS) from one year before (August 2011) to one year after (June 2013) the 2012 reform. In the first and second chapters, we developed a quasi-experimental difference-in-differences design to study the change in consumption (measured in number of monthly Defined Daily Dose (DDDs) per individual) among thirteen therapeutic groups, individuals with comorbidities -first chapter- and different age ranges -second chapter-. The policy break indicator is a three-level categorical variable that tests the existence of stockpiling between the reform’s announcement and its implementation. The treatment groups are the low-income pensioners and the middle-income working population, while the control group is the low-income working population. In the third chapter, we developed the analysis using the standard concentration index (CI). Results General analysis. Reduction (-13.04 DDDs) in consumption after the reform’s implementation, which was fully compensated by a previous increase (16.60 i.e., stockpiling) among low-income pensioners. The middle-income working population maintained its trend of increasing consumption. Therapeutic groups. Reductions in consumption after the reform’s implementation among low-income pensioners in 7 of the 13 groups, which were fully compensated for by a previous increase (i.e., stockpiling) in 4 groups and partially compensated for in the remaining 3. The analysis without the excluded medicines provided fewer negative coefficients. Comorbidities. Reduction in consumption that was only slightly compensated for by a previous increase (i.e., stockpiling). Age ranges. The consumption of prescribed paediatric medicines was not affected. The decrease among low-income pensioners was fully compensated by previous stockpiling among young adults, whereas it was only partially compensated among people aged over 40. Distributive effects. The 2012 co-payment scheme results in a more progressive distribution of private pharmaceutical expenditure than the previous co-payment scheme (i.e., CI increases from 0.03 to 0.07 for the working population). In addition, the Government proposal would entail an increase of €41.63 in annual public spending per individual. The most suitable simulations are those that establish low co-payments percentages for the poorest populations (e.g., 10%-20%) increasing them gradually, as income ranges grow. Conclusions The negative impact of cost-sharing produced, among low-income pensioners, a risk of loss of adherence to treatments, which could deteriorate the health status of individuals, especially, among pensioners within the most inelastic therapeutic groups (associated with chronic diseases) and patients with comorbidities (also, associated with chronic diseases). Notwithstanding the above, this risk was more related to the exclusion of some drugs from provision than to the cost-sharing increase. Although the reduction in consumption was influenced more by the exclusion of some medicines than by an increase in the co-payment share, we observed a loss of adherence to treatments (among senior-elderly pensioners) as a result of the co-payment increase. The use of income ranges in the 2012 reform increased progressivity slightly, although a more progressive model could have been achieved (by increasing the number of intervals). We suggest alternative more progressive co-payment systems that would maintain or, even, reduce public pharmaceutical spending.