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Purpose – This chapter offers an integrative review of psychological and neurobiological differences between younger and older adults that might impact economic behavior. Focusing on key health economic challenges facing the elderly, it offers perspectives on how these psychological and neurobiological factors may influence decision-making over the life course and considers future interdisciplinary research directions.

Methodology/approach – We review relevant literature from three domains that are essential for developing a comprehensive science of decision-making and economic behavior in aging (psychology, neuroscience, and economics), consider implications for prescription drug coverage and long-term care (LTC) insurance, and highlight future research directions.

Findings – Older adults face many complex economic decisions that directly affect their health and well-being, including LTC insurance, prescription drug plans, and end of life care. Economic research suggests that many older Americans are not making cost-effective and economically rational decisions. While economic models provide insight into some of the financial incentives associated with these decisions, they typically do not consider the roles of cognition and affect in decision-making. Research has established that older age is associated with predictable declines in many cognitive functions and evidence is accumulating that distinct social motives and affect-processing profiles emerge in older age. It is unknown how these age differences impact the economic behaviors of older people and implies opportunities for path-breaking interdisciplinary research.

Originality/value of the chapter – Our chapter looks to develop interdisciplinary research to better understand the causes and consequences of age-related changes in economic decision-making and guide interventions to improve public programs and overall social welfare.

We use a data set which contains information on a nationally representative sample of drug purchases in 1996 to investigate the relationship between the type of insurance individuals have for prescription drugs — private insurance, Medicaid, or uninsured — and both the type of drugs they purchase and the prices they pay for drugs. We find that uninsured persons use more generic drugs than privately insured persons but fewer generic drugs than Medicaid recipients. Overall, uninsured persons purchase drugs whose unit costs are 45% lower than the drugs purchased by privately insured persons and 43% lower than the drugs purchased by Medicaid recipients. Differences in unit costs across insurance types reflect differences in the market basket of drugs they purchase. To compare retail drug prices across insurance types we use standardized prices — the retail unit price of each drug relative to a benchmark price. We final that uninsured individuals pay standardized prices which are, on average, 16.5% higher than the standardized prices paid by privately insured persons, and 8.4% higher than the standardized prices paid by Medicaid recipients.

The most significant predictor for health care utilization is the individual's health status. Other factors shown to affect Medicare recipient's use of health care services are income, education, insurance, age, smoking status, place of residence, and having an ongoing relationship with a physician. Less is known about the demographic and socioeconomic factors that affect prescription drug use. Analogously to medical utilization, health status had been determined to be a significant predictor for prescription drug use. Prescription drug insurance has also been shown to increase pharmacy utilization, but its impact on overall health care costs has yet to be determined.

Objective – To examine whether local area pharmacy market structure influences contract terms between prescription drug plans (PDPs) and pharmacies under Part D.

Data – Data were collected and compiled from four sources: a national mail survey to independent pharmacies, National Council for Prescription Drug Programs (NCPDP) Pharmacy database, 2000 U.S. Census data, and 2006 Economic Census data.

Results – Reimbursements varied substantially across pharmacies. Reimbursement for 20mg Lipitor (30 tablets) ranged from $62.40 to $154.80, and for 10mg Lisinopril (30 tablets), it ranged from $1.05 to $18. For brand-name drug Lipitor, local area pharmacy ownership concentration had a consistent positive effect on pharmacy bargaining power across model specifications (estimates between 0.084 and 0.097), while local area per capita income had a consistent negative effect on pharmacy bargaining power across specifications(−0.149 to −0.153). Few statistically significant relationships were found for generic drug Lisinopril.

Conclusion – Significant variation exists in PDP reimbursement and pharmacy bargaining power with PDPs. Pharmacy bargaining power is negatively related to the competition level and the income level in the area. These relationships are stronger for brand name than for generics. As contract offers tend to be non-negotiable, variation in reimbursements and pharmacy bargaining power reflect differences in initial insurer contract offerings. Such observations fit Rubinstein's subgame perfect equilibrium model.

Implication – Our results suggest pharmacies at the most risk of closing due to low reimbursements are in areas with many competing pharmacies. This implies that closures related to Part D changes will have limited effect on Medicare beneficiaries’ access to pharmacies.

Purpose – To evaluate the efficiency consequences of the Medicare Part D program.

Methods – We develop and empirically calibrate a simple theoretical model to examine the static and the dynamic welfare effects of Medicare Part D.

Findings – We show that Medicare Part D can simultaneously reduce static deadweight loss from monopoly pricing of drugs and improve incentives for innovation. We estimate that even after excluding the insurance value of the program, the welfare gain of Medicare Part D roughly equals its social costs. The program generates $5.11 billion of annual static deadweight loss reduction and at least $3.0 billion of annual value from extra innovation.

Implications – Medicare Part D and other public prescription drug programs can be welfare-improving, even for risk-neutral and purely self-interested consumers. Furthermore, negotiation for lower branded drug prices may further increase the social return to the program.

Originality – This study demonstrates that pure efficiency motives, which do not even surface in the policy debate over Medicare Part D, can nearly justify the program on their own merits.

The doubling of obesity in the U.S. over the last 25 years has led policymakers and physicians to encourage weight loss, but few methods of weight loss are effective. One promising avenue is pharmacotherapy. However, little is known about the use of anti-obesity drugs. This paper describes the market for anti-obesity drugs and studies the utilization of anti-obesity drugs using data from the Medical Expenditure Panel Survey for 1996–2002, a period that is interesting because it covers the introduction of three, and the withdrawal of two, anti-obesity drugs from the market.

Our results point to wide sociodemographic disparities in anti-obesity drug use. Women are almost 200% more likely than men to use anti-obesity drugs. Hispanics and African-Americans are only 39% as likely as Whites to use them. Those with prescription drug coverage are 46% more likely to use anti-obesity drugs.

We also find that the vast majority of subjects who are approved to take these drugs are not taking them, and a significant number who are not approved to take the drugs are taking them. We find strong evidence that the well-publicized 1997 withdrawal of fenfluramine and dexfenfluramine had a chilling effect on the overall market for anti-obesity drugs. We find little difference in observed characteristics between those who took the withdrawn drugs and those who took the other anti-obesity drugs in the market.

Consumer-Directed Health Plans (CDHPs) are proposed as an option to control healthcare costs. No research has addressed their applicability in rural settings. This study analyzes three years (2003–2005) of healthcare expenditure and utilization incurred by two employers and a national carrier providing data from a rural state, Kentucky. The study included two measures of expenditures (health care and prescription drugs) and three measures of utilization (physician visits, hospital admissions, and hospital inpatient days). In general, the CDHP successfully controlled the growth of medical costs. These findings suggest that CDHPs may be a viable alternative benefit structure for rural employers.

Several high-profile prescription drugs have been withdrawn from the U.S. market in the last decade, yet there is no direct evidence of how a prescription drug withdrawal affects consumers’ use of remaining drugs within the same therapeutic class. In theory, remaining drugs in the therapeutic class could enjoy competitive benefits or suffer negative spillovers from the withdrawal of a competing drug. Using the Medical Expenditure Panel Survey, we test for spillovers following prescription drug withdrawals in six therapeutic classes between 1997 and 2001. Results vary, but we find stronger evidence of negative spillovers than competitive benefits. We conclude with a discussion of the characteristics of drugs and classes that may influence how remaining drugs are affected by a withdrawal in the class.

Public health policy often excludes access to essential medicines. Drawing on an in-depth case study examining access to essential medicines in the context of the HIV/AIDS pandemic in South Africa, and more briefly, making reference to the U.S. diabetes epidemic, we highlight the relationship between the need for essential medicines in world populations, and the role of groups external to government in promoting access to essential medicines in public health policy. We consider how, in the context of health stratification, the activities of patient advocacy groups, and “third way” social policies of the pharmaceutical industry generate “social capital,” creating enhanced access to essential medicines for a few, and promoting the ideal of the right to access for all. The implications for the development of public health policy inclusive of essential medicines are discussed.

Purpose – To estimate the impact of diabetic drug adherence on hospitalizations, emergency room (ER) visits, and hospital costs.

Methods – It is often difficult to measure the impact of drug adherence on hospitalizations since both adherence and hospitalizations may be correlated with unobservable patient severity. We control for such unobservables using propensity score methods and instrumental variables for adherence such as drug coinsurance levels and direct-to-consumer advertising.

Findings – We find a significant bias due to unobservable severity in that patients with more severe health are more apt to comply with medications. Thus, the relationship between adherence and hospitalization will be underestimated if one does not control for unobservable severity. Overall, we find that increasing diabetic drug adherence from 50% to 100% reduces the hospitalization rate by 23.3% from 15% to 11.5%. ER visits reduce by 46.2% from 17.3% to 9.3%. Although such an increase in adherence increases diabetic drug spending by $776 a year per diabetic, the cost savings for averted hospitalizations and ER visits are $886 per diabetic, a cost offset of $1.14 per $1.00 spent on diabetic drugs.

Originality – Most of the drug cost-offset literature focuses only on the impact of cost-sharing and drug spending on cost-offsets, making it impossible to back-out the empirical impact of actual drug adherence on cost-offsets. In this chapter, we estimate the direct impact of adherence on hospitalizations and costs.