The effect of a medication copayment increase on veterans with schizophrenia.

With the VA facing $3 billion per year in outpatient pharmacy costs, Congress implemented the Veterans Health Care Act ('Millennium Bill') in 2002. This new policy raised medication copayments from $2 to $7 for lower priority veterans, with the goal of slowing the 19% annual increase in pharmacy costs. Veterans with schizophrenia constitute a complex, chronically ill population; 40% are already antipsychotic medication non-adherent, substantially increasing their risk of hospitalization and relapse. In this study, the Health Belief Model and Donabedian's concept of benefits equity frame an examination into potential ramifications of higher copayments on medication and health services utilization among these vulnerable patients. Using data from the National Psychosis Registry, this quasi-experimental study employed longitudinal models (20-months Pre and Post copayment increase) to observe changes in the number of prescriptions filled, health services utilization and pharmacy costs between veterans subject to copayments (N = 40,654) and a natural control group of exempt individuals (N = 39,983). Analyses adjusted for relevant patient characteristics. Compared to a continual growth among exempt patients, overall prescriptions were constrained in the Copayment group following the medication cost increase. More conspicuously, refills for psychiatric drugs dropped substantially, nearly 25%. Although outpatient visits did not differ between the two groups, the risk for psychiatric admission and total inpatient days increased slightly for Copayment patients (5--10%), particularly 10--20 months following the policy change. Factoring in additional copayment revenue, the VA would realize a net revenue increase of more than $13 million annually pertaining to pharmacy services from this sub-population alone. The new policy appears to have successfully reduced pharmacy prescriptions and costs as intended. However, the marked decrease in psychiatric drug utilization and small increase in hospitalization among this seriously mentally ill population is troubling. Research studies investigating the longer-term clinical consequences of medication cost increases are required. When balancing budgetary concerns with quality care provision, benefit changes for veterans with debilitating conditions such as schizophrenia should be implemented cautiously and outcomes carefully followed. This is particularly essential within a system responsible for providing care to a rapidly aging population during an era of ongoing Medicare prescription debates.PhDHealth and Environmental SciencesHealth care managementMental healthUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/124599/2/3150125.pd