Outcomes of Reference Pricing for Angiotensin-Converting–Enzyme Inhibitors
Sebastian Schneeweiss, M.D., Alexander M. Walker, M.D., Robert J. Glynn, Ph.D., Malcolm Maclure, Sc.D., Colin Dormuth, M.A., and Stephen B. Soumerai, Sc.D.
Background In January 1997, reference pricing for angiotensin-converting–enzyme(ACE) inhibitors for patients 65 years of age or older was introducedin British Columbia, Canada. For medications within a specificclass, insurance covers the cost up to the reference price,and patients pay the extra cost of more expensive medications.Although reference pricing may reduce the costs of prescriptiondrugs, there is concern that patients may switch to less effectivemedications or stop treatment.
Methods We analyzed data from the Ministry of Health on all37,362 residents of British Columbia who were 65 or older andwere enrolled in the provincial health insurance program, receivedACE inhibitors priced higher than the reference price of $27a month in 1996, and were potentially affected by the new policy.We identified 5353 residents who switched to an ACE inhibitornot subject to cost sharing during the first six months andcompared them with 27,938 residents who received only ACE inhibitorssubject to cost sharing.
Results Reference pricing for ACE inhibitors was not associatedwith changes in the rates of visits to physicians, hospitalizations,admissions to long-term care facilities, or mortality. The probabilityof stopping antihypertensive therapy decreased as compared withthe probability before the change in policy (relative risk,0.76; 95 percent confidence interval, 0.65 to 0.89). Eighteenpercent of patients who had been prescribed ACE inhibitors subjectto cost sharing switched to lower-priced alternatives. As comparedwith patients who did not switch, those who did had a moderatetransitory increase in the rates of visits to physicians (rateratio, 1.11; 95 percent confidence interval, 1.07 to 1.15) andhospital admissions through the emergency room (rate ratio,1.19; 95 percent confidence interval, 0.99 to 1.42) during thetwo months after switching, but not subsequently.
Conclusions We found little evidence that when reference pricingfor ACE inhibitors was introduced in British Columbia, patientsstopped treatment for hypertension or that health care utilizationand costs increased.
Source Information
From the Divisions of Pharmacoepidemiology and Pharmacoeconomics (S.S., R.J.G.) and Preventive Medicine (R.J.G.), Brigham and Women's Hospital and Harvard Medical School, Boston; the Departments of Epidemiology (S.S., A.M.W., M.M.) and Biostatistics (R.J.G.), Harvard School of Public Health, Boston; the British Columbia Ministry of Health, Victoria, Canada (M.M., C.D.); and the Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, Boston (S.B.S.).
Address reprint requests to Dr. Schneeweiss at Brigham and Women's Hospital and Harvard Medical School, Division of Pharmacoepidemiology and Pharmacoeconomics, 221 Longwood Ave., Boston, MA 02115, or at schneeweiss{at}post.harvard.edu.
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