The simultaneous effects of pharmaceutical policies from payers' and patients' perspectives: Italy as a case study

OBJECTIVES The research analyses (i) the individual and interactive effects of three pharmaceutical policies (cost-sharing, prescription quotas, therapeutic reference pricing) on drugs public and private expenditure and volumes, using Italian regional policies as a case-study; (ii) the extent to which the long-run effect of policies on expenditure is mediated by prescribers’/patients’ behaviours. METHODS An enriched difference-in-differences model is used. Firstly, policies impact on public and private expenditure and volume is separately estimated. Then, the hypothesis that the effects of policies on public expenditure are mediated by behaviours (transmission mechanism) is tested. As robustness check, a possible reverse causality and feedback mechanisms is tested, by switching the mediator and the independent variable. RESULTS The analysis shows (i) that combined policies do not necessarily produce a higher impact than policies alone; (ii) a larger impact of policies in the short-run, whereas in the long-run the trend is often reversed, but not enough to compensate the final impact, which is usually in the expected direction; (iii) as for cost-sharing, that its negative impact on public expenditure is mainly due to a decrease in volumes than to a shift from public to private expenditure. CONCLUSIONS Despite its limitation, this study has shined a light on the impact of policies which are implemented in different time and places, thus covering an information gap and supporting policy-makers. Some empirical findings show also that pharmaceutical policies may have an unintended impact on health: e.g. the volumes decrease due to cost-sharing may imply patients under-treatment