The application in Catalonia in 2012 of two successive pharmaceutical co-payment measures -The euro by prescription of the Generalitat and the increase of the part paid by the patients decreed by the central Government- did not achieve a more rational use of the medicines, the stated objective of both decisions. Copayments increased revenues for administrations and they reduced the consumption of drugs, but they did it at the cost of enlarging the inequity of the health system and triggering the number of patients who did not start the treatments prescribed by their doctors. It was the lowest income, pensioners and some chronically ill people who most incurred a practice considered a relevant indicator on the health status of the population.
This is the main conclusion of the largest research done in Spain on the consequences of co-payment policies, a work of the Prisma group Parc Sanitari Sant Joan de Déu published last March by the magazine BMJ Quality & Safety. "The data reveal a worrying impact on chronic patients, the most susceptible to see their health damaged in the medium and long term," says María Rubio-Valera, principal investigator of the study.
The application of an almost universal rate of one euro per prescription – only the beneficiaries of non-contributory pensions and of the minimum income were exempt – provoked a great social response in Catalonia. "The population mobilized not only because it was unfair, but out of sheer need. After years of crisis, many could not afford it ", recalls Toni Barbará, from Dempeus per la Salut. "I was then 57 years old and I only received 426 euros. It did not come to anything. The 10 or 12 euros that I supposed each month the euro per prescription were a lot of money ", remembers Tere Morales. This woman, now retired, was one of the people who, with the complicity of some pharmacists, refused to pay the fee. "I still thank you," Morales recalls. This movement of insubordination, in which patients withdrew the drugs and signed a paper arguing their opposition, was followed by tens of thousands of Catalans.
The study monitored weekly between January 2011 and June 2014 the more than 10.6 million new treatments prescribed in the primary care centers of the Catalan Health Institute (ICS). After dividing the patients according to the income levels set by the Ministry of Health and situation -pensionists and assets-, the authors followed up on how the successive changes affected each group of population in relation to the main groups of drugs.
The results show the great swings that the co-payment measures caused on the initiation of the prescribed treatments. The entry into force of the euro by prescription in June 2012 meant that the number of pensioners and assets (workers and unemployed) with incomes of less than 5,000 euros that did not withdraw their medicines from pharmacies grew by more than 50% in some moments. . Among the assets with incomes lower than 18,000 euros, the phenomenon is also observed, although to a lesser extent: one in nine people.
This trend was consolidated in September of that year, with the entry into force of the reform of the Ministry of Health of the copay system, whereby the pensioners went on to pay 10% of the drugs and the assets were divided into three new sections. according to your income -40%, 50% and 60% – from the previous 40%.
Finally, the suspension of the euro by prescription in January 2012 – by decision of the Constitutional Court – triggered a surge in adherence to treatments. Among the lowest incomes, the percentage of those who gave up starting dropped plummeted from 20% to 14%. Among the assets with income below 18,000 euros, from 27% to 24%. And among those with higher incomes, from 25% to 23%.
The authors highlight that the non-initiation of treatments was "more pronounced in drugs with a high impact on the quality of life related to health, such as short-term analgesics and long-term chronic pain treatments".
The investigation reveals the great impact that the introduction of co-payment measures has on the population, even beyond the objective conditions of the citizens. One example is that the euro per prescription changed the behavior, among those with incomes of less than 5,000 euros per year, including those who were exempt from paying the rate, as recipients of the Minimum Insertion Income and non-contributory pensions.
Another striking case is that the mere announcement of the fee, eight months before its application, increased pharmaceutical spending due to the so-called "hoarding effect", by which doctors and patients tend to anticipate the application of the new tax. This leads the authors to qualify the savings obtained. "Some co-payment measures may increase the final costs as a result of drug hoarding and the long-term costs of non-initiation of treatments," the authors contend.
The investigation goes into an almost unexplored terrain in Spain and the rest of the world: measuring the possible negative impact on the health of the population caused by pharmaceutical co-payments. The great difficulty is to corroborate with evidence this hypothesis in the medium and long term, since after all drugs are just one more variable – along with life habits, genetics … – that influence objective data such as life expectancy. That is why researchers try to measure indirect indicators such as the initiation or not of medical treatments. "Yes it has been demonstrated that not to do it repercute in longer labor losses and worse evolution of several ailments", defends Rubio-Valera.
To similar conclusions have come the scant investigations completed in countries such as Canada. In Spain, a study done in Valencia revealed that the co-payment also reduced the follow-up of "vital treatments" like those of those who have suffered an acute coronary syndrome.
Beatriz González López, professor of Economics expert in health at the University of Las Palmas, believes that "although it is true that the copayment affects some indicators, more research is still needed to confirm that they harm the health of the population." For González, "the co-payment measures have failed in their main objective: to promote the rational use of medicines". "They have ended up being a matter more of Finance than of Health: a way to increase the collection. Patients, even low-income pensioners, have become accustomed to devoting part of their money to medicines, as they do with heating or food, "he concludes.
For Marisol Rodríguez, of the Center for Research in Economics and Health (CREB, in its acronym in Catalan), "co-payment measures can be very useful, but they have to be much better designed". "It does not make any sense, for example, to put in the same group pensioners who charge 6,000 euros a year with others who enter 90,000, even with slightly different monthly caps. Nor force to assume a 40% of the cost of medicines to workers with very low wages, while pensioners with much higher income pay 10%, "he says.
For both experts, "it would be necessary a system that, taking into account the income, was much more precise in relation to the demonstrated effectiveness of each treatment".
The Prisma group study notes "the beneficial effects of co-payment measures with an adequate design of population groups". "The reform of the Ministry of Health, although increased the contribution of almost all groups, went on to protect a very specific: assets with incomes of less than 5,000 euros a year, which previously paid 40% of drugs and were exempt. The data show that this group significantly increased its adherence to treatments ", concludes Rubio-Varela.
Cesca Zapater, a retired family doctor, still remembers "with anguish" the entry into force of the euro by prescription. "You prescribed something and there were patients who confessed to you: 'Doctor, I'm not going to be able to buy it, could not you give me a sample box? Others did not say anything to you because of embarrassment, but you suspected that they were not going to buy them. almost always you were right, "he explains.
Zapater worked in the primary care center of Vilanova del Vallés, "which is not an area of especially low income, but as a town has a bit of everything." "We were in a crisis and there were many families who had already been beaten, some warned you that what you prescribed would not be able to buy until the following month, there were cases that left you speechless." I remember an elderly man with suppurative otitis. , a very painful acute case, that pretended to wait 10 or 15 days to begin the treatment ".
For this option, other very sensitive cases were "chronic polymedicated patients". "You went over their history and you saw that they were just withdrawing some drugs, and of course they did it without criteria, you told them and they admitted that the money did not reach them all, and you were forced to tell them: 'If you can not buy them all , especially do not stop taking this and this one. "As a primary care doctor it was a tremendous thing to have to teach patients to choose between treatments, I never thought I would have to do something like that," he recalls.
Zapater recalls how some professionals resorted to ingenuity to overcome the situation. "We learned the prices and smaller containers of the drugs to detect those that cost less than 1.67 euros, below that price they did not have to pay the euro per prescription, the only good thing is that a species was created of collective conscience among doctors, social services, entities and many more people to detect the most critical cases and help them, "he concludes.