Raising Copay for Elderly Ambulatory Care May Have Adverse Consequences

Laurie Barclay, MD

September 18, 2010

January 27, 2010 — Raising cost sharing for ambulatory care among elderly patients may have negative health consequences and may increase total healthcare costs, according to the results of a study reported in the January 28 issue of The New England Journal of Medicine.

"When copayments for ambulatory care are increased, elderly patients may forgo important outpatient care, leading to increased use of hospital care," write Amal N. Trivedi, MD, MPH, from the Alpert Medical School of Brown University in Providence, Rhode Island, and colleagues. "There have been remarkably few studies of the consequences of increasing copayments for ambulatory care, and even these studies have been limited because they have excluded elderly patients or have evaluated concurrent changes in cost sharing for ambulatory care and prescription drugs. We therefore examined the effect of increasing copayments for ambulatory care on the use of acute care in the hospital among a large, nationally representative cohort of elderly Medicare enrollees in managed-care plans."

The investigators compared changes in the use of outpatient and inpatient care between enrollees in Medicare plans that increased copayments for ambulatory care and enrollees in matched control plans that made no changes in these copayments. The Medicare group consisted of 899,060 beneficiaries enrolled in 36 plans from 2001 through 2006. Mean Medicare copayments nearly doubled, increasing from $7.38 to $14.38 for primary care and from $12.66 to $22.05 for specialty care, whereas mean copayments in control plans remained unchanged at $8.33 and $11.38, respectively.

Compared with control plans, Medicare plans had 19.8 fewer annual outpatient visits per 100 enrollees in the year after the rise in copayments (95% confidence interval [CI], 16.6 - 23.1), as well as 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 - 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 - 16.6), and a 0.7 percentage point increase in the proportion of enrollees who were hospitalized (95% CI, 0.51 - 0.95).

Limitations of this study include lack of randomization of enrollees to case and control plans, short period of observation, inability to match case plans with control plans in a geographic area smaller than a census region, and lack of data on the diagnoses, procedures, and costs associated with hospital admissions and outpatient visits. In addition, the effects of increasing cost sharing for primary care visits vs specialty care visits, or the relationship between the magnitude of cost-sharing increases and subsequent use of hospital care, could not be evaluated separately.

"Raising cost sharing for ambulatory care among elderly patients may have adverse health consequences and may increase total spending on health care," the study authors write. "The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction."

Dr. Trivedi is the recipient of a Pfizer Health Policy Scholars Award and a career development award from the Veterans Affairs Health Services Research and Development Service. The study authors have disclosed no relevant financial relationships.

N Engl J Med. 2010;362:320-328.

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