Patient copayments

If a company refuses to accept the 12.5 percent price reduction, a special patient Contribution (the difference between the existing price and the new benchmark price) will apply in addition to the usual patient copayment. If a prescriber considers that there is no clinically appropriate alternative for a particular patient, the government will pay the special contribution following the prescriber seeking authority from the HIC. 

As is the case of an HMO patient presenting a card at the pharmacy, the Medicaid patient does the same thing. Each state decides whether it will have a patient copayment, and if so, its amount. About 15 States have no copayment requirement, and the others charge between 50 cents and 3.00 per prescription. 

For an example, let us consider a drug where the AWP is 60.00. The patient paid 3.00, and the pharmacy will be reimbursed 60.00 less 12%, which equals 52.80 less the 3.00 patient copayment or 49.80 by that state Medicaid agency. In addition, the pharmacy will receive 4.00 as a dispensing fee. 

One primary approach to controlling the government s pharmaceutical bill has been to enact copayment requirements, determined annually according to the Australian consumer price index (125,178). In August 1992, the patient copayment per prescription was A 15.90 for general beneficiaries (to a maximum per year of A 30, then AS2.60 to a maximum of an additional A 51.60 that year), and A 2.60 for retirees32 (up to a maximum per year of AS135.20) (178). 

When a French patient buys a drug, he or she generally pays up front for the medicine and then applies for reimbursement to the national insurance fund that covers all but the required patient copayments. 

A way for governments to save money is for part of the burden to be shifted to the patient, that is patient copayments. These are more or less universal. Two systems operate a flat-rate copayment unconnected with the price of the drug as in Ireland, the Netherlands and the UK, or a proportion of the price of the dmg as in Spain, Denmark, Belgium and France. Exemptions are common. For example, in the UK 85% of prescriptions were exempt in 2000. Encouragement of OTC drugs is another, way in which patients can be induced to contribute. Self-diagnosis and prescription worries doctors, but there has been an increase in the scope of drugs licensed for OTC sale and this may be expected to increase. 

Health maintenance organizations are the most restrictive type of managed care organization, and consumer dissatisfaction with restricted choice in HMOs likely was a significant factor in the growth of point of service (POS) plans. POS plans sometimes are referred to as open-ended HMOs. Like HMOs, enrollees typically select a primary care provider and pay no fee or a small copayment to see participating providers. POS plans differ from HMOs in that patients can receive coverage from physicians outside the network. However, patients pay more for care received from physicians outside the network and often must pay the full... 

The second group includes those countries that opt to establish copayments with a fixed monetary value Germany, Sweden, Ireland, the UK and Austria. The amount payable per package can be identical for all prescriptions (UK, Austria), or it can depend on the size of the package (Germany). In Sweden, patients pay a fixed sum in kronor for the first prescription, and a smaller sum for each subsequent prescription. 

Cost Sharing. Most states impose cost sharing on patients in the form of copayments ranging from fifty-cents to five dollars. In 1996, 29 states and the District of Columbia had adopted prescription drug copayments for all... 

More stringent forms of the copayment approach are maximum allowable cost programs. Those programs require that the patient pay the full difference between the branded prescription and the normal prescription copayment. In the extreme case, mandatory generic substitution programs require that generics be dispensed or the patient receive no reimbursement at all. 

There are different ways to look at outcomes. One method, the ECHO model, purports three basic types of outcomes economic, clinical, and humanistic (Kozma et al., 1993). Economic outcomes include direct costs and consequences, both medical and nonmedical, and indirect costs and consequences. For example, when assessing outcomes from a patient perspective, a medication copayment would be a direct medication cost, whereas gas money to pick up the medication from the pharmacy would represent a nonmedical direct cost. Lost wages from missed work could be regarded as an indirect cost. 

In the future, the accreditation process may become more focused on outcomes measurement. Eventually, health care report cards may be more accessible and easy to understand, thus helping to produce a market for quality. Some discussion of adjusting copayments to encourage patients to use providers that meet the standards purchasers have set has already occurred (Lovern, 2001). In some cases, pharmacy quality improvement may be mandated by state and local governments. For example, a new law in the state of Arizona requires that every pharmacy participate in a CQI program (Arizona Revised Statutes, 2007). 

Almost all prescriptions filled in a community pharmacy are paid for through a third-party payer, and nearly all of them are adjudicated online. Table 15-7 shows a section of WHP s Daily Plan Payment report. As depicted in this report, the manager is able to monitor the daily number of prescriptions filled for each plan, the total amount paid by each third-party payer, the total copayments made by patients, and total cost of drug products used to dispense these prescriptions. From this information, the gross margin for each payer can be calculated (as shown in the last column). Daily inspection of this report identifies plans with low reim-... 

Investors had barely digested that distasteful nugget when even more was revealed. The Wall Street Journal, analyzing an amended SEC filing, reported in earlyjuly that Merck had booked as revenue some 12.4 billion that Medco never actually received. The revenue was the 5 or 10 or 15 copayments that pharmacies collect from patients but don t pass on to Medco. 

Patienfs direcf paymenf for prescriptions has been replaced with third-party purchasers, who are agents for the ultimate payers, the health benefit sponsors (employers). Thus, patients have little knowledge of the total costs of the prescribed medications. As a result, the costs of fhe medications are hidden from patienfs because of fixed small dollar copayments or limited coinsurance costs at the point of service. 

Patients, as all consumers, want to receive the most value in products or services for the dollars they spend. Within a prescription drug benefit program, patients, as consumers, want to receive a convenient and effective treatment for the lowest out-of-pocket cost. In addition, they and their physicians expect little hindrance in providing and receiving prescribed treatments. Not encumbered by price they look for fhe mosf value, which frequently translates into the latest medication with its perceived greater value. They also want the largest quantity possible and the most medication for each plan copayment or coinsurance cost at the pharmacy. 

Employs strict quality assessment standards Conducts appropriate review of drug utilization Promotes prudent patient utilization of benefits by plan members with strategies that include copayments or plan limitations... 

Medicare is a federal health care program, and its recipients include people over the age of 65, the disabled, and those with end-stage renal disease. Medicare is administered by the Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration. The Medicare program consists of two parts (parts A and B), but is funded by four different sources (1) general tax revenues, (2) beneficiaries premiums, (3) mandatory contributions from employers and employees, and (4) deducf-ibles and copayments paid by patients. ... 

For patients who require a copayment for their medications, it is sometimes advantageous fc>r them to receive a prescription written fitr a 90-day supply (e.g., 2.5 ml bottle X 3 vs. one 2.5-ml bottle refilled three times). A 3-month prescription may avoid the cost associated with each refill and, more importantly, reduces the chances of a patient missing doses between refills. 

The Prince Edward Island plan pays for seniors welfare recipients nursing home patients and those with rheumatic fever, diabetes, tuberculosis, multiple sclerosis, AIDS, and several other conditions. New Bnmswick has an annual copayment cap for seniors and for organ transplant recipients and for selected other patient categories. A copayment is set at approximately 9 (Canadian) but is waived for some groups in Quebec, along with an annual copay ceiling of 750. 

The MHW sets prices for reimbursable drugs (those approved for the Social Insurance System). Physicians, clinics, and private hospitals are reimbursed at a price slightly higher than their actual acquisition cost. The government has scheduled annual reductions in the reimbursement prices to reduce this source of additional income to physicians. Patients make copayments of 20%, although for children and low-income elderly the copayment is waived, and recently a plan to eliminate copayments for persons 70 years of age and older was introduced. 

Fendrick AM, Smith DG, Cherew ME, Shah SN. 2001. A benefit-based copay for prescription drugs patient contribution based on total benefits, not drug acquisition cost. Am. J. MC 7(9) 861-867. 

---