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Purpose – To examine the effects of health insurance types on the use of prescribed medication that treat patients with hypertension, diabetes, and asthma. The study distinguishes between individuals with private health maintenance organization (HMO) plans and private non-HMO plans. The study also distinguishes between people with health insurance and drug coverage and people with health insurance and no drug coverage.

Methods – Joint discrete factor models are estimated to control for endogeneity of each type of coverage.

Findings – The main findings suggest that the effect of health insurance varies across patients with different conditions. The strongest and most significant effect is evident among patients with hypertension while the weakest and least significant is among patients with asthma. These findings suggest that patients with asymptomatic conditions are more likely to exhibit moral hazard than patients with conditions that impose immediate impairment. Additional results suggest that, relative to the uninsured and people with health insurance but no drug coverage, patients with drug coverage are more likely to initiate drug therapy and to consume more medications.

Originality – The results of the study indicate that moral hazard of drug utilization is condition specific. The variation in “silence” of conditions’ symptoms could be a key reason for difference in insurance effects among patients with hypertension, diabetes, and asthma.

This article presents a typology of the medicated self, as developed through in-depth interviews with twenty-two social work students and practitioners. Utilizing an interactionist perspective, the experience of taking psychiatric medication is examined in both samples, using a comparative analysis. Emphasis is placed on the impact of taking psychiatric medication on the sense of self. The data suggest that the development of a medicated self is complex and varied, and includes a small number of those who feel that medication led to an improved self, and the majority who felt damaged by their experience with medication, and expressed varying degrees of ambivalence about its use. Despite this ambivalence, most of our respondents seemed to develop an altruistic, empathetic self geared toward helping others. This self emerged in spite of respondents saying that their self was damaged. Implications are presented, and conclusions and suggestions for further work on the impact of psychiatric medication use on the self are presented.

Purpose – To examine the effect of pharmaceutical innovation on the functional status of nursing home residents.

Methodology/approach – Estimation of econometric models of the ability of nursing home residents to perform activities of daily living (ADLs) using cross-sectional, patient-level data from the 2004 National Nursing Home Survey. The explanatory variables of primary interest are the characteristics (e.g., the mean vintage (FDA approval year)) of the medications used by the resident. We control for age, sex, race, marital status, veteran status, where the resident lived prior to admission, primary diagnosis at the time of admission, up to 16 diagnoses at the time of the interview, sources of payment, and facility fixed effects.

Findings – The ability of nursing home residents to perform ADLs is positively related to the number of “new” (post-1990) medications they consume, but unrelated to the number of old medications they consume. I estimate that if 2004 nursing home residents had used only old medications, the fraction of residents with all five ADL dependencies (number of activities for which the resident is not independent) would have been 58% instead of 50%.

Social implications – During 1990–2004, pharmaceutical innovation reduced the functional limitations of nursing home residents by between 1.2% and 2.1% per year.

Originality/value of chapter – The first public-use survey of nursing homes that contains detailed information about medication use, and better data on functional status than previous surveys, is used to help explain why there has been a significant decline in the functional limitations of older people.

Purpose – The authors focus on understanding the relationship between costs and cost sharing on medication adherence for individuals who initiated a disease-modifying therapy (DMT) for the treatment of multiple sclerosis (MS). DMTs reduce the risk of relapse and are an essential component of MS treatment. Furthermore, the authors compare monthly payment levels for copayments versus coinsurance and estimate the effects on adherence.

Methods – Using the MarketScan Commercial Claims and Encounters database evidence from July 1 2005 to March 31 2008, the authors employ a multivariate two-stage least-squares model (2SLS) to examine the impact of copayments or coinsurance on the medication possession ratio (MPR).

Findings – Descriptive results show that the mean out-of-pocket (OOP) costs of DMT per month were higher for patients with coinsurance than for patients with copayments. For the cohort of patients with copayment there was little difference in monthly copayments across adherence thresholds. Regression analysis shows that an increase in cost sharing reduces adherence overall, but this effect was small and insignificant in the copayment cohort. In contrast, in the coinsurance cohort increased cost sharing was significantly associated with decreased adherence to DMT medication; with a 10% increase in cost sharing leading to an 8.6% decline in adherence.

Implications – Employers increasingly rely on coinsurance, despite evidence that reliance on coinsurance results in lower adherence. Our research findings suggest that coinsurance appears to be a greater obstacle to compliance, confirming predictions found in the theoretical literature.

Originality – This research converted counts of injectable treatments into a continuous adherence measure. Previous literature on cost sharing did not examine MS.

Purpose – The purpose of this study is to estimate the own- and cross-price elasticity of brand-name outpatient prescription drug cost-sharing for maintenance medications and to estimate the effects of changes in the price differential between generic and brand-name prescription drugs.

Methodology/approach – We first review the literature on the effects of an increase in brand-name drug patient cost-sharing. In addition, we analyze two examples of utilization patterns in filling behavior associated with an increase in brand-name cost-sharing for patients in employer-sponsored health plans with chronic illness.

Findings – We found that the own-price elasticity of demand for brand-name prescription drugs was inelastic. However, the cross-price elasticity was not consistent in sign, and utilization patterns for generic prescription fills did not always increase after a rise in brand-name cost-sharing.

Research limitations – The empirical examples are limited to the experience of patients with employer-sponsored health insurance.

Practical implications – The common practice of increasing brand-name prescription drug patient cost-sharing to increase consumption of generic drugs may not always result in higher generic medication use. Higher brand-name drug cost-sharing levels may result in discontinuation of chronic therapies, instead of therapeutic switching.

Originality/value of chapter – The value of this chapter is its singular focus on the effects of higher brand-name drug cost-sharing through a synthesis of the literature examining the own- and cross-price elasticity of demand for brand-name medications and two empirical examples of the effects of changes in brand-name cost-sharing.

This chapter uses Goffman’s concept of total institutions in a comparative case study approach to explore the role of psychotropic drugs in the process of transinstitutionalization.

This chapter interprets psychotropic drug use across four institutionalized contexts in the United States: the active-duty U.S. military, nursing homes and long-term care facilities, state and federal prisons, and the child welfare system.

This chapter documents a major unintended consequence of transinstitutionalization – the questionable distribution of psychotropics among vulnerable populations. The patterns of psychotropic use we synthesize suggest that total institutions are engaging in ethically and medically questionable practices and that psychotropics are being used to serve the bureaucratic imperatives for social control in the era of transinstitutionalization.

Psychotropic prescribing practices require close surveillance and increased scrutiny in institutional settings in the United States. The flows of mentally ill people through a vast network of total institutions raises questions about the wisdom and unintended consequences of psychotropic distribution to vulnerable populations, despite health policy makers’ efforts regulating their distribution. Medical sociologists must examine trans-institutional power arrangements that converge around the mental health of vulnerable groups.

This is the first synthesis and interpretive review of psychotropic use patterns across institutional systems in the United States. This chapter will be of value to medical sociologists, mental health professionals and administrators, pharmacologists, health system pharmacists, and sociological theorists.

Mental health medications are used to treat a broad range of symptoms that can be experienced by individuals with one of the autistic spectrum disorders (ASDs). The psychoactive medications are targeted toward the specific symptom rather than the disorder itself. The medications work either by enhancing or mimicking a natural process, and they either increase or decrease the activity in an area of the brain or affect a communication route within the brain.Many clinical trials have demonstrated the usefulness of mental health medications for altering the psychological and biological functioning of the individual treated. Medications work best in conjunction with and coordinated with psychological, educational, and social interventions designed to enhance the individual's functioning. No medication is without side effects, and an analysis of the potential benefits and risks of the use of a medication must be undertaken when medication to enhance an individual's functioning is considered.

We study research designs where a binary treatment changes discontinuously at the border between administrative units such as states, counties, or municipalities, creating a treated and a control area. This type of geographically discontinuous treatment assignment can be analyzed in a standard regression discontinuity (RD) framework if the exact geographic location of each unit in the dataset is known. Such data, however, is often unavailable due to privacy considerations or measurement limitations. In the absence of geo-referenced individual-level data, two scenarios can arise depending on what kind of geographic information is available. If researchers have information about each observation’s location within aggregate but small geographic units, a modified RD framework can be applied, where the running variable is treated as discrete instead of continuous. If researchers lack this type of information and instead only have access to the location of units within coarse aggregate geographic units that are too large to be considered in an RD framework, the available coarse geographic information can be used to create a band or buffer around the border, only including in the analysis observations that fall within this band. We characterize each scenario, and also discuss several methodological challenges that are common to all research designs based on geographically discontinuous treatment assignments. We illustrate these issues with an original geographic application that studies the effect of introducing copayments for the use of the Children’s Health Insurance Program in the United States, focusing on the border between Illinois and Wisconsin.