Page 52 - Effective healthcare cost containment policies Using the Netherlands as a case study - Niek W. Stadhouders

Chapter 3
One systematic review (16 studies) concluded that internal reference pricing lowered payer spending in most cases, but also increased patient cost sharing, resulting in a marginal reduction in total expenditure (Lee et al., 2015). A Danish reform (2005), replacing external reference pricing with internal reference pricing, reduced pharmaceutical spending by 10% (Kaiser et al., 2014). One review found lower costs in four of its eight included studies on substitution from brand-name drugs to clinically equivalent counterparts (generics), while no difference was found in clinical outcomes (Gothe et al., 2015). The authors commented that although acquisition costs of the target drug declined, increases in inpatient and outpatient utilisation compensated for this. This specific review did not take into account the possibility that pharmaceutical companies may increase prices of other drugs as a result of generic substitution (Mestre-Ferrandiz, 2003). Contrary to these findings, a study on mandatory generic substitution between 1997 and 1999 found drug cost reductions of $36 to $52 (a significant 8% reduction) per health plan member (Joyce et al., 2002).
We found evidence for 17 interventions that aim to control volumes from seven studies and ten reviews (179 studies). Four interventions target supply, and thirteen interventions target demand for care, specifically cost sharing (6 interventions) and benefit restrictions (5 interventions).
Volume controls
Already in 1974 the RAND Health Insurance Experience (HIE) demonstrated in a large randomised controlled trial that cost sharing can contain expenditure (Manning et al., 1987; Newhouse et al., 1981). We included six papers that confirmed this finding. One review (12 studies) found that high-deductible consumer directed health plans (CDHC) reduced plan expenditure with 5%-15%, corrected for enrolee characteristics (Bundorf, 2016). Plans with high coinsurance also bared lower expenditure (Feldstein and Wickizer, 1995). One review (29 studies) concluded that both user charges and coinsurance lower drug expenditures (Lee et al., 2015). A second review (19 studies) reported drug cost savings even after a small increase in copayments, but also found reduced access to necessary medications (Soumerai et al., 1993). In addition, insurance plans with higher drug copayments were found to have 27% lower pharmaceutical expenditures. Additionally, two-tier plans with higher copayments for branded drugs had lower spending than single tier plans (7-22%). Extra copayments for non-preferred brands had an additional cost-decreasing effect (2-7%) (Joyce et al., 2002). Also for independent practice associations, increasing pharmaceutical copayments from $5.00 to $7.50 resulted in an estimated 12% reduction in pharmaceutical expenditures. For Health Maintenance Organisations, the reduction of pharmaceutical expenditure (3%) was non-significant, suggesting either that copayments were less effective
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