When insurance companies pass a larger share of the costs of asthma medications along to families, children aged 5 years or older use slightly less medication and are hospitalized more frequently, report researchers in this week’s JAMA. But such cost sharing had no significant effect on medication use or hospitalization among children younger than this age threshold.
Few studies have probed the effects of cost sharing on medication use in children. To investigate this issue, Anupam B. Jena, MD, PhD, of Massachusetts General Hospital and Harvard Medical School, and his colleagues conducted a retrospective cohort study of 8834 US children with asthma to analyze the effects of out-of-pocket costs on medication adherence, hospitalization, and emergency department use. They found that the average out-of-pocket cost of a year of asthma medication was about $150. An increase in the out-of-pocket cost for a medication led to reduced medication use among children 5 years old or older but not younger children. The authors noted that this age-related difference might be because younger children are more likely to have more severe asthma or their parents may more tightly control their medication use. Older children whose medications costs were higher also had more hospitalizations but did not make more emergency department visits. Dr Jena discussed the findings with news@JAMA.
news@JAMA: Why did you and your colleagues decide to do the study?
Dr Jena: In the adult population, it is well known that higher out-of-pocket prices are associated with reductions in medication utilization. There is an unintended effect of reduced use—increased hospitalization. But no one has looked at this phenomenon in children. We do know access to health insurance is a huge impediment to medication access for children. Yet we know little about how cost affects medication utilization among the 45 million children covered by private insurance.
news@JAMA: How much of an impact did cost sharing have on medication use?
Dr Jena: The impact of prices was small, not as large as we thought it would be. We estimated the costs for a standard basket of asthma medications across plans and found a range of annual out-of-pocket costs from $100 to $190. It appears parents are a little less responsive to out-of-pocket prices for their child’s medication than for their own.
news@JAMA: Were there any surprises?
Dr Jena: We also found that children’s annual adherence to asthma medications was quite low; on average, prescriptions were filled for only about 40% of the year. That estimate is a little lower than the adherence rate in adults.
Children who had one parent with asthma had slightly better adherence to asthma medication. The parent with asthma may better understand the importance of taking medication regularly.
news@JAMA: How did increasing out-of-pocket costs affect medical utilization?
Dr Jena: The effects of cost are mild to moderate, but even with that, there is an increased use of other health care services.
The total expenditures on asthma-related hospitalization went up slightly with increased medication costs. Hospitalization for children with asthma increased from 1.7 per 100 to 2.4 per 100 children when the cost of medications increased by $100. But the total costs of hospitalization went up only slightly because hospitalization for asthma is so rare.
news@JAMA: Do you think reducing or eliminating out-of-pocket costs for these drugs would help?
Dr Jena: There have to be other ways for providers to improve adherence that have nothing to do with cost. Lowering cost would probably increase adherence and reduce health care costs, but not as much as other things. A paper in the New England Journal of Medicine looked at adult patients with heart attack and randomized some to receive free medication when they left the hospital and found that adherence was still low. Adherence in the control group was about 40%; with free medication, adherence only went up to 45%. So how much improvement could you get from making medication free? The next step is deciding whether paying patients may help.
news@JAMA: Besides reducing costs, what could be done to boost adherence?
Dr Jena: Things like providing the child with a referral to a pulmonologist and making sure the family has a written plan of care. These things would ensure the parents and the child are well educated about how to care for the child’s asthma symptoms.