From the city to the bush: increases in patient co-payments for medicines have impacted on medicine use across AustraliaAnna Kemp A B G , John Glover C , David B. Preen A , Max Bulsara D , James Semmens E and Elizabeth E. Roughead F
A Centre for Health Services Research, School of Population Health, The University of Western Australia, 35 Stirling Hwy, Crawley, WA 6009, Australia. Email: email@example.com
B Illawarra Health and Medical Research Institute, IHMRI, Building 32, University of Wollongong, Wollongong, NSW 2522, Australia.
C Population Health Information Development Unit, University of Adelaide, Adelaide, SA 5001, Australia. Email: firstname.lastname@example.org
D Institute for Health and Rehabilitation Research, University of Notre Dame Australia, PO Box 1225, Fremantle, WA 6959, Australia. Email: email@example.com
E Curtin Health Innovation Research Centre, Curtin University, GPO Box U1987, Perth, WA, Australia. Email: firstname.lastname@example.org
F Sansom Institute, School of Pharmacy and Medical Sciences, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia. Email: email@example.com
G Corresponding author. Email: firstname.lastname@example.org
Australian Health Review 37(1) 4-10 http://dx.doi.org/10.1071/AH11129
Submitted: 15 December 2011 Accepted: 28 May 2012 Published: 19 November 2012
Aim. To determine whether the national declines in prescription medicine use occurring after the 2005 21% increase in co-payments affected all areas of Australia or were specific to remote and disadvantaged areas.
Methods. Observed dispensing of proton pump inhibitors (PPIs) and statins were obtained for 1392 statistical local areas (SLA) of Australia in 2004 and 2006. Expected dispensing was based on national dispensing rates and was age standardised to each SLA. Expected dispensing for 2006 was based on pre-2005 prescription trends. Ratios of observed to expected dispensing (dispensing ratios) for each SLA were calculated. Mean dispensing ratios for each medicine and year were calculated for all remoteness and disadvantage groups. Generalised regression models compared the percentage change in dispensing ratios from 2004 to 2006.
Results. Between 2004 and 2006 PPI dispensing fell significantly in major cities (-13.7%, 95% CI = –17.3–-9.8), inner regional (-14.0, 95%CI = -19.5–-8.2), outer regional (-14.6%, 95%CI = -19.9–-9.0) and remote areas (-9.4%, 95%CI = -16.4–-1.8). Statin dispensing fell in all groups but the most remote (range 6–7%). When focussing on disadvantage, PPI dispensing fell significantly in all groups (range 12–15%). Statins dispensing did not fall significantly in the most disadvantaged areas (-2.9%, 95%CI = -8.6–3.2) but did in the least (-6.5%, -11.3–-1.5) and second-least (-5.8, -10.5–-0.9) disadvantaged areas. Dispensing of PPIs and statins in the most remote and disadvantaged areas remained substantially below levels expected for Australia after the 21% co-payments increase.
Conclusions. The findings suggest that the 2005 21% in patient co-payments adversely affected prescription medicine use in all areas of Australia and was not specific to remote or disadvantaged areas. Indeed, dispensing of statins fell significantly in all but the most remote and disadvantaged areas, and the existing gap in dispensing of PPIs and statins was not widened by the co-payments increase. PPIs, which are used at above-prevalence rates in Australia and have cheaper over-the-counter substitutes available, were more sensitive to co-payment increases than were statins.
What is known about the topic? Despite high levels of chronic illness in geographically remote and socially disadvantaged areas of Australia, prescription medicine use is generally lowest in these areas. In 2005, co-payments for publically subsidised medicines increased by 21%. After this increase, utilisation of many medicines fell at the national level. It is not known whether these falls in utilisation were specific to remote or disadvantaged areas or if decreases occurred across all areas of Australia.
What does this paper add? Between 2004 and 2006 PPI dispensing decreased significantly across all remoteness groups (major cities, inner regional, outer regional and remote areas) and statin dispensing fell significantly in all but remote areas. When focusing on disadvantage groups, dispensing of PPIs fell across Australia, and statins fell significantly in all but the most disadvantaged areas.
What are the implications for practitioners? The effect of the 2005 21% increase in co-payments was not specific to remote or disadvantaged areas and was associated with decreases in dispensing across Australia.
References Stocks N, Ryan P, Allan J, Williams S, Willson K. Gender, socioeconomic status, need or access? Differences in statin prescribing across urban, rural and remote Australia. Aust J Rural Health 2009; 17 92–6.
| Gender, socioeconomic status, need or access? Differences in statin prescribing across urban, rural and remote Australia.CrossRef | 19335599PubMed |
 Stocks N, Ryan P, McElroy H, Allan J. Statin prescribing in Australia: socioeconomic and sex differences. Med J Aust 2004; 180 229–31.
| 14984343PubMed |
 Senes S, Penm E. Medicines for cardiovascular health: are they used appropriately? Canberra: AIHW; 2007.
 Australian Institute of Health and Welfare. Cardiovascular medicines and primary health care: a regional analysis. Canberra: AIHW; 2010.
 Schoen C, Osborn R, How SKH, Doty MM, Peugh J. In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008. Health Aff 2009; 28 w1–16.
| In chronic condition: experiences of patients with complex health care needs, in eight countries, 2008.CrossRef |
 Lehnbom E, Boxall A, Russell L, Brien J. Management of medicines in chronic illness: views of community pharmacists in New South Wales. J Pharm Pract Res 2009; 39 207–10.
 Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward higher-performance health systems: adults’ health care experiences in seven countries, 2007. Health Aff 2007; 26 w717–34.
| Toward higher-performance health systems: adults’ health care experiences in seven countries, 2007.CrossRef |
 Schoen C, Osborn R, Huynh PT, Doty M, Zapert K, Peugh J, et al Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Aff 2005; 24 w509–25.
 Kemp A, Roughead E, Preen DB, Glover J, Semmens J. Determinants of self-reported medicine underuse due to cost: a comparison of seven countries. J Health Serv Res Policy 2010; 15 106–14.
| Determinants of self-reported medicine underuse due to cost: a comparison of seven countries.CrossRef | 20203082PubMed |
 Department of Health and Ageing. Past copayments and safety net thresholds; 2010. Available at http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs-general-pbs-copayment.htm [verified 15 December 2010]
 Hynd A, Roughead E, Preen DB, Glover J, Bulsara M, Semmens J. Increased patient co-payments and changes in subsidised prescription medicines dispensed in Western Australia. Aust N Z J Public Health 2009; 33 246–52.
| Increased patient co-payments and changes in subsidised prescription medicines dispensed in Western Australia.CrossRef | 19630844PubMed |
 Hynd A, Roughead E, Preen DB, Glover J, Bulsara M, Semmens J. The impact of co-payment changes on dispensings of government-subsidised medicines in Australia. Pharmacoepidemiol Drug Saf 2008; 17 1091–9.
| The impact of co-payment changes on dispensings of government-subsidised medicines in Australia.CrossRef | 18942671PubMed |
 Australian Government Department of Health and Ageing. Expenditure and prescriptions twelve months to 30 June 2010. Canberra; 2010.
 Australian Institue of Health and Welfare. Statistical Local Area. Canberra: AIHW; 2006. Available at http://meteor.aihw.gov.au/content/index.phtml/itemId/327460 [verifed 14 October 2011].
 Commonwealth Department of Health and Aged Care. Measuring remoteness: Accessibility/Remoteness Index of Australia (ARIA), Revised Edition. Canberra: Department of Health and Aged Care; 2001.
 Australian Bureau of Statistics. An introduction to socio-economic indexes for areas (SEIFA). Canberra: ABS; 2006.
 Hollingworth S, Duncan EL, Martin JH. Marked increase in proton pump inhibitors use in Australia. Pharmacoepidemiol Drug Saf 2010; 19 1019–24.
| Marked increase in proton pump inhibitors use in Australia.CrossRef | 20623646PubMed |
 SAS Institute Incorporated. SAS/ETS Users Guide Version 9. Cary, NY: SAS Institute Incorporated; 2003.
 ArcGIS. ArcMap 10. Redlands, California: ESRI; 2010.
 Australian Bureau of Statistics. Information paper: census of population and housing - socio-economic indexes for areas, Australia, 2001 Canberra: ABS; 2003. Cat. 2039.0.
 Department of Health and Ageing. Alternative arrangements for medicines: Aboriginal health services - Section 100. Canberra: DoHA; 2010. Available at http://www.health.gov.au/internet/main/publishing.nsf/Content/health-pbs-indigenous-faq [verified 1 November 2011]
 Piette JD, Heisler M, Horne R, Alexander GC. A conceptually based approach to understanding chronically ill patients’ responses to medication cost pressures. Soc Sci Med 2006; 62 846–57.
| A conceptually based approach to understanding chronically ill patients’ responses to medication cost pressures.CrossRef | 16095789PubMed |
 Essue B, Kelly P, Roberts M, Leeder S, Jan S. We can’t afford my chronic illness! The out-of-pocket burden associated with managing chronic obstructive pulmonary disease in western Sydney, Australia. J Health Serv Res Policy 2011; 16 226–231.
| 21954233PubMed |
 Doran E, Robertson J, Salkeld G. Pharmaceutical Benefits Scheme cost sharing, patient cost consciousness and prescription affordability. Aust Health Rev 2011; 35 37–44.
| Pharmaceutical Benefits Scheme cost sharing, patient cost consciousness and prescription affordability.CrossRef | 21367329PubMed |