The impact of pharmacotherapy policy: a case study

Universal drug insurance coverage has been endorsed by the National Health Forum and the Liberal government as a means of providing equitable access to prescription medication for Canadians. In 1996, Quebec legislated a universal drug insurance program. To finance extended coverage for approximately 1.2 million previously uninsured beneficiaries, an income-indexed coinsurance and deductible cost-sharing policy was introduced for previously insured beneficiaries (people 65 years of age and older, and those receiving income security allowance). The increase in cost-sharing for previously insured beneficiaries led to a reduction in both essential (senior citizens: 9.1%; income security: 14.4%) and less essential medication (senior citizens: 15.1%; income security: 22.4%). Reductions in the use of essential drugs were associated with an increase in the rate of emergency visits (by 43% in senior citizens and 78% in income security recipients) and adverse events (by over 100% in senior citizens and 88% in income security recipients). The 442 physicians and pharmacists who were surveyed reported that the policy reduced the use of antilipidemics, inhaled steroids and antihypertensives in the previously insured beneficiaries, but improved access to previously unaffordable medications for cardiac disease and asthma in the newly insured beneficiaries. Although universal drug insurance appeared to enhance access to essential medication for the newly insured, these benefits were exacted at a cost of producing unintended health effects in two vulnerable subgroups: senior citizens and income security recipients. Because no prior studies have shown that consumer cost sharing can lead to expected objective of selective reductions in less essential drug use alone, alternate policy approaches for financing universal drug coverage need to be considered.