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Drug benefit caps reduce use of essential drugs among older people who have multiple chronic illnesses

About 6 million elderly Americans receive medical care in Medicare health maintenance organizations (HMOs). Most of these HMOS (68 percent) have drug benefit limits, for example, $200 per quarter. Many Medicaid programs serving the lowest income older people also have implemented monthly drug coverage limits. Older people who are least likely to be taking essential medications because of a reimbursement cap are those with multiple chronic illnesses that require drug therapy, especially those with a mental health component, according to a study supported in part by the Agency for Healthcare Research and Quality (HS05947).

Stephen B. Soumerai, Sc.D., of Harvard Medical School, and his colleagues examined changes in the standard monthly dose of essential medications after initiation of a New Hampshire Medicaid reimbursement cap of three medications per month among 343 chronically ill Medicaid enrollees (half of whom were aged 75 or older; all were 60 years or older). They regularly used essential medications for heart disease, asthma/chronic obstructive pulmonary disease, diabetes, seizures, or coagulation disorders, and they received an average of three or more prescriptions per month during the year prior to the cap.

Following the drug prescription cap, mean standard doses of essential medications fell 34 percent. Bigger reductions in use of essential medications were associated with a greater number of precap medications, greater number of coexisting illnesses, longer hospitalizations, and greater use of outpatient services. The three illnesses associated with the largest relative reduction in essential drug use were psychoses/bipolar disorders, anxiety/sleep problems, and chronic pain. Arbitrary drug benefit limits clearly reduce use of needed medications by the frailest community-dwelling older people with multiple physical and mental illnesses which, in turn, can lead to increased hospitalizations or nursing home entry, concludes Dr. Soumerai.

See "Utilization of essential medications by vulnerable older people after a drug benefit cap: Importance of mental disorders, chronic pain, and practice setting," by Eric E. Fortess, Sc.D., M.P.H., Dr. Soumerai, Thomas J. McLaughlin, Sc.D., and Dennis Ross-Degnan, Sc.D., in the June 2001 Journal of the American Geriatrics Society 49(6), pp. 793-797.

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