The reference price system and socioeconomic differences in ... - KCE

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30 Reference Price System KCE reports 126 3.3.2 Association of the RPS with drug use A number of studies in the 4 reviews analyzed the association of the RPS with drug use. Most of these studies conclude that the implementation of a reference price system was followed by an increase in the use of drugs priced at the reference price and by a decrease in the use of higher cost drugs within the cluster. Goldman et al. (2007) concluded that almost all studies included in their review found large increases in the use of drugs priced at or below the reference price and the opposite effect for higher-cost drugs that require patient cost sharing (because of the RPS). Some studies examined the impact of reference pricing during the mid-1990s in British Columbia for senior citizens for 3 categories of drug treatment (nitrate drugs, ACE-inhibitors, and calcium channel blockers (CCBs). These studies are included in all 4 reviews. 27, 55-57 They found that between 9% and 34% of patients switched to fully covered (reference) drugs after implementation of the RPS. The overall use of CCBs declined according to Grootendorst and colleagues, whereas Schneeweiss and colleagues came to the conclusion that this reduction was not statistically significant after controlling for pre-policy trends. With respect to the use of ACE-inhibitors, the opposite result was found. Four studies 27, 55, 57-61 reported in the review of Aaserud et al. (2006) observed an increase in reference drug use (between 60% and 196%) after the transition period following the implementation of a RPS. The use of the cost share drugs in the reference groups decreased immediately after the implementation of reference pricing system. The decrease was estimated between 19% and 42% 27, 57, 60-62 . The effect on the total use of drugs was smaller and not consistent among individual studies. 3.3.3 Association of the RPS with drug prices In general, most of the studies found that the implementation of a RPS was followed by a price reduction for drugs covered by the RPS. The review of Aaserud et al. (2006) contained 2 studies assessing the association of reference pricing with drug prices. A reduction in drug prices was found ranging from 11% to 26% for different reference drug groups. Grading the quality of the evidence showed very low quality in both studies. In a more recent study, based on panel regression, Brekke et al. (2009) 63 observed that the introduction of reference pricing in Norway led to an average price reduction of about 18% on brand names and 8% on generics. 3.3.4 Association of the RPS with drug expenditures In general, most of the studies tend to conclude that the introduction of a RPS contributed to a reduction of drugs expenditures for the third-party payer, at least in the short term. In Aaserud et al. (2006) a trend towards an immediate reduction in expenditures for the drug in the reference group was found (ranging from -5% to 50%), based on 4 studies. 27, 55, 57, 64 The same studies were included in the review by Goldman et al. (2007). According to the review of Aaserud et al. (2006) not enough evidence was found to determine the impact of reference pricing on patient co-payments.
KCE Reports 126 Reference Price System 31 3.3.5 Association of the RPS with health services use and health A limited number of studies have assessed the impact of the implementation of a reference price system on health (mortality) and health care utilization. All of these studies are based on individual data. Most of them found no evidence of adverse effects on health and no evidence of a significant change in health care utilization after the introduction of a reference price system. In Aaserud et al. (2006) no significant differences in health outcomes (mortality) and health care utilization as measured in the individual studies were found. Measures of health care utilization were emergency room visits, and hospital admissions through the emergency department, non-emergency hospital admissions and physician office visits. However, the quality of the evidence in the 4 included studies was graded as very low. Comparable results were found in the other reviews. Key points The review of the literature on reference pricing showed that the introduction of reference pricing: • was followed by an increase in use of drugs priced at the reference price and by a decrease in use of the highest cost drugs within the cluster. • was not systematically followed by a reduction in the price of the original branded drugs submitted to the RPS. • contributed to a reduction of drugs expenditures for the third-party payer. • had no significant impact on health or health care utilization. All conclusions should be considered with caution given the lack of transferability of the results to the general population (many studies limited to senior citizens in British Columbia). Moreover, most of the studies focused on the short-term impacts.
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