Hsu John, Price Mary, Huang Jie, Brand Richard, Fung Vicki, Hui Rita, Fireman Bruce, Newhouse Joseph P, Selby Joseph V
Division of Research, Kaiser Permanente, Oakland, Calif 94612, USA.
N Engl J Med. 2006 Jun 1;354(22):2349-59. doi: 10.1056/NEJMsa054436.
Little information exists about the consequences of limits on prescription-drug benefits for Medicare beneficiaries.
We compared the clinical and economic outcomes in 2003 among 157,275 Medicare+Choice beneficiaries whose annual drug benefits were capped at 1,000 dollars and 41,904 beneficiaries whose drug benefits were unlimited because of employer supplements.
After adjusting for individual characteristics, we found that subjects whose benefits were capped had pharmacy costs for drugs applicable to the cap that were lower by 31 percent than subjects whose benefits were not capped (95 percent confidence interval, 29 to 33 percent) but had total medical costs that were only 1 percent lower (95 percent confidence interval, -4 to 6 percent). Subjects whose benefits were capped had higher relative rates of visits to the emergency department (relative rate, 1.09 [95 percent confidence interval, 1.04 to 1.14]), nonelective hospitalizations (relative rate, 1.13 [1.05 to 1.21]), and death (relative rate, 1.22 [1.07 to 1.38]; difference, 0.68 per 100 person-years [0.30 to 1.07]). Among subjects who used drugs for hypertension, hyperlipidemia, or diabetes in 2002, those whose benefits were capped were more likely to be nonadherent to long-term drug therapy in 2003; the respective odds ratios were 1.30 (95 percent confidence interval, 1.23 to 1.38), 1.27 (1.19 to 1.34), and 1.33 (1.18 to 1.48) for subjects using drugs for hypertension, hyperlipidemia, and diabetes. In each subgroup, the physiological outcomes were worse for subjects whose drug benefits were capped than for those whose benefits were not capped; the odds ratios were 1.05 (95 percent confidence interval, 1.00 to 1.09), 1.13 (1.03 to 1.25), and 1.23 (1.03 to 1.46), respectively, for subjects with a systolic blood pressure of 140 mm Hg or more, a serum low-density-lipoprotein cholesterol level of 130 mg per deciliter or more, and a glycated hemoglobin level of 8 percent or more.
A cap on drug benefits was associated with lower drug consumption and unfavorable clinical outcomes. In patients with chronic disease, the cap was associated with poorer adherence to drug therapy and poorer control of blood pressure, lipid levels, and glucose levels. The savings in drug costs from the cap were offset by increases in the costs of hospitalization and emergency department care.
关于医疗保险受益人的处方药福利受限的后果，目前了解的信息较少。
我们比较了2003年157,275名医疗保险 + 选择计划的受益人（其年度药物福利上限为1000美元）和41,904名受益人的临床及经济结果，后者因雇主补充福利而享有无限制的药物福利。
在对个体特征进行调整后，我们发现福利受限的受试者，其适用于福利上限的药品费用比福利不受限的受试者低31%（95%置信区间为29%至33%），但总医疗费用仅低1%（95%置信区间为 -4%至6%）。福利受限的受试者前往急诊科就诊的相对率较高（相对率为1.09 [95%置信区间为1.04至1.14]）、非选择性住院的相对率较高（相对率为1.13 [1.05至1.21]）以及死亡的相对率较高（相对率为1.22 [1.07至1.38]；差异为每100人年0.68 [0.30至1.07]）。在2002年使用治疗高血压、高脂血症或糖尿病药物的受试者中，福利受限的受试者在2003年更有可能不坚持长期药物治疗；使用治疗高血压、高脂血症和糖尿病药物的受试者的相应比值比分别为1.30（95%置信区间为1.23至1.38）、1.27（1.19至1.34）和1.33（1.18至1.48）。在每个亚组中，药物福利受限的受试者的生理结果比福利不受限的受试者更差；收缩压为140毫米汞柱或更高、血清低密度脂蛋白胆固醇水平为每分升130毫克或更高、糖化血红蛋白水平为8%或更高的受试者的比值比分别为1.05（95%置信区间为1.00至1.09）、1.13（1.03至1.25）和1.23（1.03至1.46）。
药物福利上限与较低的药物消费和不良临床结果相关。在患有慢性病的患者中，福利上限与较差的药物治疗依从性以及血压、血脂水平和血糖水平控制不佳相关。药物福利上限节省的药物成本被住院和急诊科护理费用的增加所抵消。
