Greater medication cost-sharing associated with reduced use of asthma medications by children

Greater out-of-pocket asthma medication cost was associated with small reductions in medication use and with more frequent asthma-related hospitalizations among children ages 5 years or older, according to a study in the March 28 issue of JAMA.

"In recent years, private health plans have attempted to contain medication costs by shifting costs toward patients. Among adults, greater patient medication cost sharing has been associated with reduced medication use and increases in emergency department (ED) visits and hospitalizations. Similar data are limited among children, although nearly 45 million children in the United States are privately insured. Barriers to health care clearly exist for uninsured children, but the association of greater medication cost sharing with the health care decisions insured families make for their children has been overlooked," according to background information in the article. Asthma is the most prevalent chronic disease of childhood.

Pinar Karaca-Mandic, Ph.D., of the University of Minnesota, Minneapolis, and colleagues examined how prescription medication cost sharing for asthma among privately insured families was associated with medication and other health care use by children in those families. The researchers obtained data on pharmacy and medical claims for 37 geographically diverse U.S. employers and conducted an analysis of insurance claims for 8,834 U.S. children with asthma who initiated asthma control therapy between 1997 and 2007. Of the children in the study, 2,921 were younger than 5 years (average age, 2.5 years) and 5,913 were ages 5 to 18 years (average age, 9.7 years). The researchers estimated models of asthma medication use, asthma-related hospitalization, and emergency department visits with respect to out-of-pocket costs and child and family characteristics.

The researchers found that across plans, the average out-of-pocket cost of asthma medications per year was $154 among those ages 5 to 18 years and $151 among those younger than 5 years. Average use of asthma control therapy was low in both age groups. Among children ages 5 to 18 years, filled asthma prescriptions covered an average of 40.9 percent of days; among children younger than 5 years, prescriptions covered 46.2 percent of days. Annual average rates of asthma-related emergency department visits and hospitalization were greater among children younger than 5 years (7.9 percent and 4.7 percent, respectively) vs. children ages 5 to 18 years (3.7 percent and 2.1 percent, respectively).

The authors also found that an increase in out-of-pocket medication costs from the 25th to the 75th percentile was associated with a reduction in adjusted medication use among children ages 5 to 18 years (41.7 percent vs. 40.3 percent of days) but no change among younger children. Adjusted rates of asthma-related hospitalization were higher for children ages 5 to 18 years in the highest quartile of out-of-pocket asthma medication costs compared with the lowest quartile (2.4 vs. 1.7 hospitalizations per 100 children), but no statistically significant difference across quartiles was found for children younger than 5 years. Annual adjusted rates of emergency department use did not vary across out-of-pocket quartiles for either age group.

The researchers write that their results contribute to ongoing discussions about generosity mandates for children. "In addition to prohibiting health plans from limiting coverage of children with preexisting health conditions, the Affordable Care Act requires plans to cover preventive health services such as vaccines and well child visits at no cost to families. Our study suggests that medication generosity mandates have small effects on use and asthma-related hospitalizations, but other strategies to improve medication use, such as routine access to primary care and pulmonary specialists, written plans of care for families, and regularly scheduled follow-up appointments may be important in improving medication use."

"Low levels of medication use suggest that parents may not realize the benefits of prescription medications in childhood chronic illness. It is perhaps not surprising that children with asthmatic parents, who are presumably familiar with the importance of consistent medical therapy, had higher use of asthma medications than children of parents without asthma. Ultimately, despite its limitations, our study suggests that greater prescription medication cost sharing among children with asthma may lead to small reductions in use of important medications with unintended consequences of more frequent asthma-related hospitalizations," the authors conclude.

(JAMA. 2012;307[12]:1284-1291. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: Support was provided by the National Institute of Child Health and Human Development, the National Institute on Aging, and the Roybal Center for Health Policy Simulation. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.

Please Note: For this study, there will be multimedia content available, including the JAMA Report video, embedded and downloadable video, audio files, text, documents, and related links. This content will be available at 3 p.m. CT Tuesday, March 27 at this link.

In an accompanying editorial, Wendy J. Ungar, M.Sc., Ph.D., of the Hospital for Sick Children and the University of Toronto, writes that there is a misalignment between the price and need for asthma medications, and that tiered formularies and value-based insurance design have been proposed as possible solutions.

"These approaches set co-payment levels in proportion to potential health benefit. The most needed drugs would have the lowest level of cost sharing, creating an incentive for patients to adhere properly to their drug regimens. However, cost-sharing levels of necessary drugs need to remain low enough so as not to deter acquisition and shift program costs to families. Value-based insurance design was included in the 2010 Affordable Care Act and in October 2011 was a recommendation in the Institute of Medicine's Essential Health Benefits report. Other drug policies, such as those governing the Quebec provincial drug plan, have abolished cost sharing for children's prescription medications. Recognizing that fully covering services and interventions that promote child health may deter or prevent serious or chronic diseases in the adult years is perhaps the best form of value in drug policy reform."

(JAMA. 2012;307[12]:1316-1318. Available pre-embargo to the media at www.jamamedia.org)

Editor's Note: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. In 2011, Dr. Ungar was a paid consultant for the Ontario Public Drug Programs Division, Drug Programs Services Branch, Ontario Ministry of Health and Long-term Care.