Large amounts of health care money are spent on drugs, and these amounts are increasing. Spending more on drugs could mean less money for hospitals, doctors or even other non-health care services. There is also misuse, overuse and underuse of appropriate drugs which can lead to wasted resources and health hazards. There is therefore a pressure to ensure better use of drugs and to control the costs of drugs, but without decreasing health benefits.
This review found 21 studies that evaluated policies implemented by governments, non-government agencies and health insurance companies to improve drug use or to save (third-party) drug spending or both. Five policies were evaluated in which people pay directly for their drugs when they fill their prescription:
caps (prescription drugs are reimbursed up to a maximum amount and then after this amount people have to pay for their drugs),
fixed co-payments (people pay a fixed amount per prescription or drug),
tier co-payments (people pay a fixed amount per prescription or drug which may depend, for example, on whether the drug is a brand name or a generic name),
coinsurance (people pay a percent of the price of the drug),
ceilings (people pay for part of or full price of the drug up to a maximum amount, for example, for a year, and then people pay no or less money for drugs after that amount).
It is thought that if people have to pay directly for their drugs they may decrease their use of drugs (either overall, or for drugs considered to be over-prescribed or a less cost-effective alternative than other available treatments); they may buy cheaper drugs; or they may pay for their own drugs, or both.
This review found that cap and co-payment polices can decrease overall drug use and decrease third-party drug spending. But reductions in drug use were found for both life-sustaining drugs and drugs that are important in treating chronic conditions, as well as in other drugs. Although insufficient data on health outcomes were available, large decreases in the use of drugs that are important for peoples' health may have adverse effects. This could lead to an increased use of healthcare services and therefore, overall spending. Policies in which people pay directly for their drugs are less likely to cause harm if only non-essential drugs are included in these policies or exemptions are built into the policies to ensure that people receive needed medical care.