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Generic-Only Coverage In Medicare HMOs Leads To Higher Out-Of-Pocket Costs,
Lower Drug Use For Enrollees, Health Affairs Study Says

Hospitalizations Increase, But Drug Plans Save Under Coverage Rules In Place
For 1.2 Million Medicare Beneficiaries In 2002

BETHESDA, MD — Medicare HMOs that changed their pharmacy benefits to cover only generic drugs reduced their costs but increased out-of-pocket costs and reduced health care quality for many of their enrollees, according to a new study published today by Health Affairs and the California HealthCare Foundation.

The study of more than 550,000 Medicare HMO enrollees in California found that those whose drug coverage changed from brand-name and generic in 2001 to generic-only in 2002 reduced their overall use of prescription medication, with a reduction in use of brand-name drugs and an increase in the use of generic medications compared with members of a control group whose coverage did not change.

Hospital admissions, meanwhile, rose by 3.02 per 1,000 members for those whose drug coverage changed to generic only, compared with declining slightly for those whose coverage did not change, according to the study.

The switch to generic-only coverage had an upside in reducing HMO costs. Average monthly costs for the health plans fell by $11 per member with generic-only coverage, from $105 in 2001 to $94 in 2002, but rose slightly from $108 to $110 for those whose coverage stayed the same.

But at the same time, out-of-pocket costs increased for enrollees with generic-only coverage. Average monthly per member out-of pocket costs rose $16.60 between 2001 and 2002, from $30.90 to $47.50. For those whose coverage remained the same, average out-of-pocket costs rose by less — $13.22 (from $26.27 to $40.49).

Author Jennifer Christian-Herman, associate director of Health Services Research at Cerner Health Insights in Beverly Hills, California, and two colleagues also studied prescription drug use in five clinical areas: congestive heart failure, coronary artery disease, diabetes, epilepsy, and antidepressant medication use.

When compared with the control group whose coverage did not change, there was a statistically significant reduction in prescription drug use among those with generic-only coverage for all chronic conditions except epilepsy.

“The study demonstrated that switching to a generic-only benefit changed drug-use patterns and lowered total pharmacy costs for the Medicare HMO population studied,” Christian-Herman says. “However, evidence suggesting a negative effect on quality of care was noted overall and across four clinical areas. Given the mixed findings, it appears that a generic-only benefit may not be an optimal solution at this time.”

In 2002, 26 percent of Medicare HMOs covered generic medications only — nearly three times the rate in 2001. That number translates to 1.2 million Medicare HMO members with generic-only coverage.

Christian-Herman’s coauthors at Cerner Health Insights were Matthew Emons, principal investigator, and Dorothy George, senior associate director.

The article can be read at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.455.

Health Affairs, published by Project HOPE, is a bimonthly multidisciplinary journal devoted to publishing the leading edge in health policy thought and research.

The California HealthCare Foundation (CHCF) is an independent philanthropy committed to improving California’s health care delivery and financing systems. For more information, visit www.chcf.org.


©2004 Project HOPE–The People-to-People Health Foundation, Inc.