ENDEP : A virtual network to provide evidence on pharmaceutical policiesPatient charges in Europe and patients and physicians’ decision making process

Dr C HuttinCoordinator ENDEP network, EIASMPresentation for Gastein meeting, september 2002Website: www.eiasm/internationalprojects/endep

HISTORY OF ENDEP

• CREATION in 1994 of a virtual think tank, to provide scientific evidence to European decision-makers on the impact of pharmaceutical policies

• DEVELOPMENT STAGE supported by the Human capital and mobility program: sharing knowledge and building trust

• Pilot study: comparing what a European consumer has to pay out of pocket in different national health systems

• BIOMED: an integrated project with standardisation of methodologies.

• CENTRALISATION OF DATA

Patient charges in Europe and patients and physicians’ decision making process

• To examine whether and how cost to the patient through different reimbursement systems in Europe influence physicians treatment choices and patient behaviours

• To cosntruct new indicators on cost to the patient,cost to the providers and societal costs.

• To bring evidence useful for policy circles at EU level,using international comparisons (in particular in the context of the agenda of monitoring of health systems (Sanco, e.g. Echi)

These costs correspond to different prescription charge arrangements in European countries

Countries Type of charge and level of charge

Deductible and ceiling on patient

AUSTRIA Fixed 3.15 per pack

FINLAND Graduated above a fixed cost deductible

0;25;50% above deductible

France Graduated 0;35;65% of drug cost

ITALY Fixed charge

GERMANY Fixed charge

1.56;2.60;3.64 depending on pack size

UK Fixed charge

Patient charges and patients and physicians’decision making process

(Methods on the physician side) The conceptual basis: an adaptation of the Lens model

(Brunswick, 52; Cooksey, 90), Hammond,95:theoretical background of probability functionalism)

Patient cues Economic cues

True State Judged State

Corrected weights Clinical cuesJudged weights

Patient charges and cost sensitivity analysis of GPs in various European countries

2. Final design for the research on cost sensitivity of GPs jointly agreed between the ENDEP/EIASM consortium and the commercial Skim partner using conjoint analysis

Given a patient profile:

Q1: How would you treat this patient ?Q2: To what extent did you take patient cost into account when you decided how to treat this Patient ? (scale 1-7)

Patient characteristics: patient affordability,patient requestfor cheaper treatment,

severity of disease (hay fever) or risk factors (hypertension), patients’expenses

On other diseases

PATIENT CHARGE AND PHYSICIANS’COST SENSITIVITY

MAIN RESULTS

Results France: average utility values

-1 -0,5 0 0,5 1

good income/insurance

poor/insurance

poor/no insurance

patient doesn’t ask

patient asks cheaper

certain days/5 cigarettes

all season/40 cigarettes

all season severe/ 40 cigarettes father died 52

no other disease

other prescr FF 50

other prescr FF 200

hay fever hypertension

Results the UK : average utility values

-1 -0,5 0 0,5 1

good income

moderate income

low income

patient doesn’t ask

patient asks cheaper

certain days/5 cigarettes

all season/40 cigarettes

all season severe/ 40 cigarettes father died 52

no other disease

1 other prescr

3 other prescr

hay fever hypertension

Results Finland : average utility values

-1 -0,5 0 0,5 1

good income

moderate income

low income

patient doesn’t ask

patient asks cheaper

certain days/5 cigarettes

all season/40 cigarettes

all season severe/ 40 cigarettes father died 52

no other disease

1 other prescr

3 other prescr

hay fever hypertension

Results Italy : average utility values

-1 -0,5 0 0,5 1

good income

moderate income

low income

patient doesn’t ask

patient asks cheaper

certain days/5 cigarettes

all season/40 cigarettes

all season severe/ 40 cigarettes father died 52

no other disease

1 other prescr

3 other prescr

hay fever hypertension

LINKING COST SENSITIVTY INDEX FOR EACH INDIVIDUAL PHYSICIAN WITH PRESCRIBING INTENTION SHIFTS

PRESCRIBING INTENTION SHIFTSFOR HYPERTENSION IN FRANCE

-0,15 -0,10 -0,05 0,00 0,05 0,10 0,15

Beta bloqueurs

Antagonistesangiotensine 2

Inhibiteurscalciques

IEC(s)

Diurétiques

PRESCRIBING INTENTION SHIFTSFOR HYPERTENSION IN THE UK

-0,10 -0,05 0,00 0,05 0,10

2-3 months

1 month

no drug treatment atall

other drug treatment

beta blocker

calcium antagonist

ACE inhibitor

diuretic

PRESCRIBING INTENTION SHIFTSFOR HAY FEVER IN FRANCE

-0,10 -0,05 0,00 0,05 0,10

LOMUSOL

PRIMALAN

TELFAST

FLIXONASE

DERINOX

NASALIDE

MIZOLLEN

NASONEX

VIRLIX

BECONASE

NASACORT

OPTICRON

ALLERGODIL

ZYRTEC

CLARITYNE

PRESCRIBING INTENTION SHIFTSFOR HAY FEVER IN THE UK

-0,20 -0,10 0,00 0,10 0,20

2-3 months

1 month

no drug treatment at all

eye drops

nasal steroid

non-sedating antihistamine

Patient charges and patients decision making process

main hypotheses for EU policy making

H1 : Cost conscious patients have poorer health status H2 : Cost conscious patients are higher users of

prescribed drugs and GP visits H3 : Cost conscious patients are higher users of cost

reduction strategies H4 : Non exempt patients are higher users of cost reduction

strategies H5 : Lower household income groups are more cost conscious H6 : Lower household income groups are higher users of

cost reduction strategies

0

10

20

30

40

50

60

70

80

90

Fin costcon

Fin noncost

Aus cost c Aus noncost

Cost conscious hypertensive patients have poorer health status only in

Finland and Austria

low comorb

high comorb

0

10

20

30

40

50

60

70

80

90

100

Fincostcon

Finnoncost

Auscost

c

Ausnoncost

Frgcostcon

Frgnoncost

Cost conscious patients are higher drug users than non cost conscious patients in

Finland, Austria and Germany

high users cc

low users cc

0

10

20

30

40

50

60

70

80

90

100

Fin cost con Fin non cost

Cost conscious patients are higher users of GP visits only in Finland

high users cc

low users cc

Fin Fr Aus Frg I UK

use

0102030405060708090

100

Finnish, British and Italian cost conscious patients significantly avoid

seeing their physicians

use

do not use

Fin Fr Aus Frg I UK

use

0102030405060708090

100

British, Finnish,Italian and German cost conscious patients significantly wait till they

are paid to get their prescriptions

use

do not use

0

5

10

15

20

25

30

35

40

45

Fin Fr Aus Frg I UK

Finnish, British and Italian cost conscious patients are predominant users of the cost reduction strategies

initiated by the patient

use S1

use S2

use S3

use S4

use S5

use S6

0

10

20

30

40

50

60

70

80

Fin Fr Aus Frg I UK

In fixed prescription charge systems, the prescription of longer supply is the most used cost reduction strategy with the GP

advice, by cost conscious patients

use S1

use S2

use S3

0

10

20

30

40

50

60

70

Fin Fr Aus Frg I UK

French, British, Italian and Finnish cost conscious patients

are high users of strategies where they ask pharmacist's advice

use S1

use S2

use S3

use S4

use S5

use S6

POLICY IMPLICATIONS

• ROLE OF SCIENCE AND EVIDENCE IN EUROPEAN POLICY

• MORE CONVERGENCE OF HEALTH INSURANCE SYSTEMS ?

• GENERATION OF PRIMARY DATA FOR THE DEVELOPMENT OF HEALTH MONITORING SYSTEMS