In Budget 2017, the €25 cap on prescription charges on the Medical Card scheme was reduced to €20 for people over 70 years, effective from March 1st 2017. Why is this important? Good adherence to medicines is difficult for all of us to achieve. Copayments for medicines represent an additional barrier to good adherence, in addition to other factors such as fear of side effects or simple forgetfulness for example. The issue of copayments threatening adherence to medicines is amplified in the Medical Card population in Ireland, because those who are socio-economically disadvantaged, as well as those who are aged ≥ 70 years are overrepresented in this population.
My PhD research tracked the impact of a 50c prescription charge (introduced 2010) and its’ subsequent increase to €1.50 in 2013 on adherence to essential and less-essential medicines. Essential medicines are those that are typically used in chronic disease, and are life sustaining. An example is medicines used to treat diabetes. Less-essential medicines are often used in symptom control and often don’t address the underlying cause of disease. An example of a less-essential medicine is a painkiller. It is important to highlight the distinction between essential and less-essential medicines because the intention of copayments is often to decrease the use of less-essential medicines, while not jeopardising the use of essential medicines.
The introduction of the 50c copayment resulted in an immediate reduction in adherence to both essential and less-essential medicines. Adherence to less-essential medicines declined more (up to -9%) than adherence to essential medicines (up to -5%). The major exception to this pattern was for anti-depressant medications, where adherence declined by 8%, which was larger than the reductions in adherence to the other essential medicines used to treat diabetes or high blood pressure or high cholesterol.
The increase in copayment from 50c to €1.50 was associated with an immediate reduction in adherence to most medications (except those used to treat diabetes). Similar to the 50c copayment, adherence to less-essential medicines was impacted upon more than essential medicines. However, again, anti-depressants did not follow this pattern; a decrease of 10% in adherence to anti-depressants was noted in comparison to declines of less than 4.4% for other essential medicines
There was no evidence for continued decreases in adherence in the months following the policy interventions. This means that adherence fell after the copayments were introduced, but did not continually decrease month by month after this initial reduction.
These findings were communicate via a 3 page Health Policy Brief to the Minister of Health ahead of Budget 2015. The copayments were not increased in that Budget, and have not been changed until the most recent Budget where the monthly cap has been reduced for those aged ≥70 years.
The link between health services research and policy is highlighted by this research. It is imperative that policy makers are made aware of ongoing research on the Irish Healthcare system and services to help inform their policy making decisions. While research from other settings is helpful, it is not always applicable to the Irish setting. A forthcoming publication from my PhD in the journal Health Policy speaks to the issue of using evidence on the impact of copayments from health care settings in North America. It concludes that differences between health systems can often be highly nuanced, which negatively impacts on the generalisability of policy related evidence from one setting to another.
While recent changes to the copayment policy are encouraging, much work remains to be done to generate evidence for future changes. For example, the impact of the €2.50 copayment on adherence to medicines has yet to be analysed. Further, the results observed for anti-depressant medicines should be further explored. Lastly, a study to examine whether an association exists between copayments on the medical card scheme and increased clinical outcomes such as heart attack, stroke or worsening diabetes should be carried out. The ongoing role out of the Unique Health Identifier in Ireland may make it possible in the future to link pharmacy claims data with hospital data to analyse whether such associations exist.
Dr. Sarah-Jo Sinnott,
London School of Hygiene and Tropical Medicine
- Sinnott, S. J., et al. (2016). “Copayments for prescription medicines on a public health insurance scheme in Ireland.” Pharmacoepidemiol Drug Saf 25(6): 695-704
- Sinnott, S.J., et al. (2016). “The international generalisability of evidence for health policy: a cross country comparison of medication adherence following policy change”. Accepted Health Policy, October 2016.
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