Table 5 Results — association between prescription drug insurance/cost-sharing and healthcare services utilization, general population

Gibson, Ozminkowsky, Goetzel, 2005 [19];

In most studies, higher levels of prescription drug cost-sharing were not associated with changes in the utilization of low-intensity outpatient medical services, such as physician office visits, outpatient visits, and home health visits. However, these studies assessed small changes in prescription drug cost sharing. Two studies reported an increase in high-intensity health services (such as inpatient visits, emergency department visits, readmissions among older patients hospitalized with complications after acute myocardial infarction) as cost-sharing rose in some diagnostic groups (congestive heart failure or coronary artery disease) while not in others (diabetes mellitus). Four studies reported no association between higher levels of cost-sharing and high-intensity services.

Magnitude: n/a

Goldman, Joyce, Zheng, 2007 [23];

Increased drug copayments were not associated with more outpatient visits, hospitalizations, or emergency department visits among a broader population (not restricted to the elderly or those with chronic conditions).

Magnitude: n/a

Gemmil, Thomson, Mossialos, 2008 [24];

There was generally a positive relationship between prescription drug cost-sharing and outpatient, inpatient, and emergency care. Studies also found that prescription limits increased the frequency of partial hospitalization and nursing home admissions and the use of emergency mental health service. Two studies that found no effect were based on chronically ill patients.

Magnitude: unclear.

Remler, Greene, 2009 [25];

Some evidence suggested that pharmaceutical cost-sharing increased emergency department use and hospitalizations; limited evidence about resulting increases in outpatient care.

Magnitude: unclear.

Green, Maclure, et al., 2010 [26];

The effects of pharmaceutical reimbursement on health care access were uncertain. Some studies reported an immediate increase in utilization while another found no significant difference in office visits, hospitalization, or length of stay. Very few studies looked at the long-term impact on utilization. One study reported an increase in outpatient services but no change in inpatient and long-term services.

Magnitude: unclear.

Eaddy, Cook, et al., 2012 [32];

Most studies indicated that increased patient drug cost-sharing adversely affected health services utilization (emergency department visits, outpatient visits, preventative services, hospitalizations and nursing-home admissions). Fewer studies indicated that an increase in cost-sharing did not affect medical utilization or number of medical visits.

Magnitude: unclear.

Kiil, Houlberg, 2014 [37];

Overall, pharmaceutical copayments had positive effects on the substitution to other types of health care services (such as hospitalization, accident emergency departments, long-term care, general practise consultation);

Magnitude: unclear

Kesselheim, Huybrechts et al., 2015 [39];

Multiple studies found that limiting drug insurance was associated with an increase in the use of health services including emergency department use, hospitalizations, nursing home admissions, psychiatric hospitalizations, outpatient mental health visits, and emergency mental health services; other studies found that the expansion of drug insurance led to reductions in hospitalizations.

Magnitude: one study reported the effect of reaching the coverage limit in Medicare Part D on emergency department use and hospitalizations (RR 1.6; 95%CI 1.4, 1.8; RR 1.9, 95%CI 1.6, 2.1). Another study reported positive associations between reaching the Part D coverage gap and worse outcomes among patients in psychiatric institutions with schizophrenia and bipolar disorder, including hospitalizations (schizophrenia: HR 1.3; 99.5%CI 1.1, 1.7; bipolar disorder: HR 1.3; 99.5%CI 1.0, 1.6).

Luiza, Chavez et al., 2015 [40];

The effects of pharmaceutical cost-sharing on emergency department use, hospitalization or use of outpatient care were uncertain.

Magnitude: unclear.

Gupta, McColl et al., 2018 [46];

– Canadians

Evidence regarding the impact of cost-related nonadherence on individual health outcomes such as disease exacerbation, poor self-reported health, increase in symptoms leading to increasing hospitalizations, emergency department visits, or mortality was limited and mixed. Two studies found that relative to those with no drug insurance, the insured made more use of physician services.

Magnitude: unclear.

Kolasa, Kowalcyzk, 2019 [50];

All 11 included studies found positive associations between increases in out-of-pocket expenses for drugs and the use of health care services (9 of 11 found associations that were statistically significant). Health care services included physician visits, hospitalization, and emergency room visits.

Magnitude: unclear.