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BACKGROUND: For atrial fibrillation (AF) patients, oral anticoagulants (OACs) can reduce the risk of stroke by 60%; however, nearly 50% of patients recommended to receive OACs do not receive therapy. Integrated insurers that cover pharmacy and medical benefits may be incentivized to improve OAC use and adherence because they benefit from offsets in medical costs associated with prevented strokes. OBJECTIVE: To compare OAC use and adherence between AF patients enrolled in Medicare stand-alone prescription drug plans (PDPs), which only cover pharmacy benefits, and those enrolled in Medicare Advantage prescription drug (MAPD) plans, which cover medical and pharmacy benefits. METHODS: This was a retrospective cohort study, conducted using 2014-2016 Medicare claims data from the Centers for Medicare & Medicaid Services and a large regional health plan in Pennsylvania. Primary outcomes included OAC use and OAC adherence. OAC use was measured as filling at least 1 prescription for an OAC after AF diagnosis. OAC adherence was defined as having greater than or equal to 80% of days covered with an OAC. We constructed conditional logistic regression models in propensity score-matched samples to test the association between enrollment in PDPs or MAPD plans and outcomes. RESULTS: There were 2,551 AF patients enrolled in PDPs and 4,502 in MAPD plans before propensity score matching. The propensity score-matched sample included 2,537 patients in each group. OAC use was higher among MAPD beneficiaries (74%-76%) compared with PDP beneficiaries (70%; P < 0.001), and 41%-42% of MAPD beneficiaries were adherent to OACs, compared with 34% of PDP beneficiaries (P < 0.001). In adjusted analyses among propensity score-matched samples, PDP enrollment was associated with lower odds of OAC use (OR = 0.67, 95% CI = 0.56-0.81) and adherence (OR = 0.68, 95% CI = 0.59-0.78) compared with MAPD enrollment. CONCLUSIONS: AF patients enrolled in MAPD plans were more likely to use and adhere to OACs compared with PDP enrollees. These results may reflect the financial incentives of MAPD plans to improve guideline-recommended OAC use, since MAPD insurers bear the risk of pharmacy and medical costs and thus may benefit from cost savings associated with averted stroke events. As efforts to improve use and adherence of OACs in AF patients increase, focus should be given to how insurance benefit designs can affect medication use. DISCLOSURES: No outside funding supported this study. Hernandez has received personal fees from BMS and Pfizer, unrelated to this study. The other authors have nothing to disclose.

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OBJECTIVE: To determine the amount of variation in numbers and types of medications requiring prior authorization (PA) by insurance plan and type. METHODS: Most health insurance companies require PA for medications to ensure safe and effective use and contain costs. We generated 4 lists of medications that required PA during 2017 for commercial, marketplace, Medicaid, and Medicare plans. We aggregated medications according to the generic medication name equivalent using codes and medication names. We compared these medications to assess how many of the medications required PA by 1, 2, 3, or all 4 of the insurance plans. We counted all prescription orders written for a patient age 18 years or older with health plan insurance during 2017 for any of the medications that appeared on the health plan's PA lists by querying the electronic health record. RESULTS: PA was required for 600 unique medications in 2017 across the 4 plans. Of 691,457 prescription orders written for 114,159 members, 31,631 (5%) were written for 1 of the 600 medications that required PA by at least 1 insurance plan. There were 12,540 medication orders (written for 6,642 members) that potentially required PA. The marketplace plan required PA for the greatest number of medications (440), followed by the Medicare (272), commercial (271), and Medicaid (72) plans. The most commonly prescribed classes of medications for which PA was required by at least 1 plan were antihyperlipidemics (22% of orders potentially requiring PA), narcotic analgesics (13%), hypnotics (12%), antidiabetic medications (9%), and antidepressants (9%). For only 25% of medications (151 of 600) was PA required by at least 3 plans, and for only 5% (32 of 600) was PA required by all 4 insurance types. CONCLUSION: Medications requiring PA can differ within a single health insurance company, but this variation may be unavoidable due to external factors.

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OBJECTIVE: To analyse the medicines prescription, prescription filling, payment expenditure for medicines by ambulatory health service users (HSU) in 2006, and to evaluate its evolution in the last 12 years. MATERIAL AND METHODS: Using data from the National Health Surveys in 2006 three binary logistic regression models were constructed to identify the variables associated with the prescription rate, prescription filling and payment for medicines in 2006. The results of access to medicines were compared to the ones from previous National Health Services from 1994 and 2000. RESULTS: The type of health service provider was found to be the most important predictors of access to medicines. Although the proportion of HSU obtaining a prescription and paying for drugs has broadly stayed the same as in 1994, the percentage of HSU paying for their prescribed medicines decreased from 70% in 1994 to 42% at Ministry of Health institutions in 2006. CONCLUSION: The progress in prescription and population access to medicines has been uneven across health service providers.

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OBJECTIVE: To analyse the medicines prescription, prescription filling, payment expenditure for medicines by ambulatory health service users (HSU) in 2006, and to evaluate its evolution in the last 12 years. MATERIAL AND METHODS: Using data from the National Health Surveys in 2006 three binary logistic regression models were constructed to identify the variables associated with the prescription rate, prescription filling and payment for medicines in 2006. The results of access to medicines were compared to the ones from previous National Health Services from 1994 and 2000. RESULTS: The type of health service provider was found to be the most important predictors of access to medicines. Although the proportion of HSU obtaining a prescription and paying for drugs has broadly stayed the same as in 1994, the percentage of HSU paying for their prescribed medicines decreased from 70 percent in 1994 to 42 percent at Ministry of Health institutions in 2006. CONCLUSION: The progress in prescription and population access to medicines has been uneven across health service providers.

OBJETIVO: Analizar la prescripción médica, surtimiento de recetas y gasto en medicamentos que tienen los usuarios del primer nivel de los servicios de salud (UPNS) en 2006 y evaluar su evolución en los últimos 12 años. MATERIAL Y MÉTODOS: Utilizando los datos de la Encuesta Nacional de Salud de 2006 se construyeron tres modelos de regresión logística para identificar los factores asociados con la prescripción, el surtimiento de medicamentos y el pago por medicamentos recetados. Se compararon los resultados del acceso a medicamentos con los de encuestas anteriores de 1994 y 2000. RESULTADOS: La variable más relevante para el acceso a medicamentos fue el tipo de institución donde se prestó atención. Aunque al nivel global la proporción de los UPNS que obtuvieron una prescripción y que pagaron por los medicamentos más o menos se mantuvo estable, el porcentaje de los UPNS que pagaron por los medicamentos en las instituciones de la Secretaría de Salud disminuyó de 70 a 42 por ciento entre 1994 y 2006. CONCLUSIÓN: El mejoramiento del acceso a medicamentos para usuarios de los servicios de salud ha sido desigual a través de las instituciones.

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OBJECTIVES: To describe the pharmaceutical services offered at the primary care level by Brazil's Sistema Unico de Salud (Universal Health Care System). METHODS: The study took place in Londrina, Paraná, in January-March 2003. The World Health Organization's recommended drug use indicators were employed. Included in the study were 13 primary health care facilities in which 390 patients were interviewed. RESULTS: None of the facilities had a pharmacist. The average office visit lasted 8.6 minutes; the mean number of drugs prescribed was 2.2; and injections were given in 10.9%. Generic drugs were prescribed 66.5% of the time and 73% of the prescribed drugs were included in the Lista Municipal de Medicamentos Esenciales (Municipal List of Essential Drugs). Only 46.6% of the patients interviewed reported having the basic instructions required for appropriate use of the drug prescribed. CONCLUSIONS: These results can aid in restructuring the municipality's pharmaceutical services because they underscore the need to improve and to increase rational drug use as a therapeutic resource imperative to supporting health efforts.

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OBJETIVOS: Caracterizar a los servicios farmacéuticos de atención primaria del Sistema Único de Salud (SUS) de Brasil. MÉTODOS: El estudio se llevó a cabo en Londrina, Paraná, Brasil, de enero a marzo de 2003. Se utilizaron los indicadores de uso de los medicamentos propuestos por la Organización Mundial de la Salud. Se incluyeron 13 unidades de atención primaria de salud, donde se entrevistaron 390 pacientes. RESULTADOS: Ninguna de las unidades contaba con un farmacéutico. El promedio de duración de la consulta médica fue de 8,6 minutos; el de medicamentos por prescripción, 2,2; y el de uso de inyectables, 10,9 por ciento. La denominación genérica se utilizó en 66,5 por ciento de las prescripciones y 73,3 por ciento de los medicamentos constaban en la Lista Municipal de Medicamentos Esenciales (Remume). Solamente 46,6 por ciento de los pacientes entrevistados refirieron tener la información mínima para usar correctamente los medicamentos prescritos. CONCLUSIÓN: Estos resultados pueden contribuir para la reorganización de los servicios farmacéuticos en el municipio, ya que señalan la necesidad del fortalecimiento y del uso racional de medicamentos como recursos terapéuticos necesarios para apoyar a las acciones de salud.

OBJECTIVES: To describe the pharmaceutical services offered at the primary care level by Brazil's Sistema Único de Salud (Universal Health Care System). METHODS: The study took place in Londrina, Paraná, in January-March 2003. The World Health Organization's recommended drug use indicators were employed. Included in the study were 13 primary health care facilities in which 390 patients were interviewed. RESULTS: None of the facilities had a pharmacist. The average office visit lasted 8.6 minutes; the mean number of drugs prescribed was 2.2; and injections were given in 10.9 percent. Generic drugs were prescribed 66.5 percent of the time and 73 percent of the prescribed drugs were included in the Lista Municipal de Medicamentos Esenciales (Municipal List of Essential Drugs). Only 46.6 percent of the patients interviewed reported having the basic instructions required for appropriate use of the drug prescribed. CONCLUSIONS: These results can aid in restructuring the municipality's pharmaceutical services because they underscore the need to improve and to increase rational drug use as a therapeutic resource imperative to supporting health efforts.

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OBJECTIVE: Measure and compare the percentage of prescriptions fully dispensed to persons with and without Popular Health Insurance (SPS in Spanish) who use ambulatory and general hospital services associated with the Mexico State Health Services (SESA in Spanish), and taking into account insurance status. SESA user satisfaction was also measured with respect to access to medication. MATERIAL AND METHODS: Information for the study was taken from four surveys of SESA ambulatory and hospital units that included probabilistic samples with state representativity. Samples of ambulatory units were selected by stratification according to level of care and association to the SPS service network. RESULTS: The findings indicate that the percentage of prescriptions fully dispensed in SESA ambulatory units has improved, reaching approximately 90%, especially among those units offering services to persons affiliated with SPS. Nevertheless, these percentages continue to be lower than those of ambulatory units associated with social security institutions. Percentages of prescriptions fully dispensed have also improved in SESA hospital units, but continue to be relatively low. In nearly all states, as the percentage of prescriptions fully dispensed has increased, user satisfaction with access to medication has also improved. CONCLUSIONS: In 2006 more than 50% of the states had high levels of fully dispensed prescriptions among persons with SPS (> or =90%). The more significant problem exists among hospitals, since only 44% of users who received a prescription in SESA hospitals in 2006 had their prescriptions fully dispensed. This finding requires a review of SPS medication policies, which have favored highly prescribed low-cost medications at ambulatory services at the expense of higher cost and more therapeutically effective medications for hospital care, the latter having a greater impact on household budgets.

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OBJETIVO: Medir y comparar el porcentaje de recetas surtidas completamente a los usuarios de servicios ambulatorios y de los hospitales generales de los Servicios Estatales de Salud de México (SESA) afiliados y no afiliados al Seguro Popular de Salud (SPS) según condición de aseguramiento, además de medir la satisfacción de los usuarios de los SESA con el acceso a los medicamentos. MATERIAL Y MÉTODOS: La información del estudio procede de cuatro encuestas de unidades ambulatorias y hospitalarias de los SESA que contaron con muestras probabilísticas de representatividad estatal. Las muestras de las unidades ambulatorias se seleccionaron mediante estratificación por nivel de atención y por condición de pertenencia a la red de servicios del SPS. RESULTADOS: Los hallazgos indican que el porcentaje de recetas completamente surtidas ha mejorado en las unidades ambulatorias de los SESA, sobre todo en aquellas que ofrecen servicios a los afiliados al SPS y que alcanzan porcentajes de casi 90 por ciento. Estos porcentajes, sin embargo, siguen siendo inferiores a los de las unidades ambulatorias de las instituciones de seguridad social. Los porcentajes de recetas surtidas en las unidades hospitalarias de los SESA también han mejorado, pero siguen siendo relativamente bajos. En casi todas las entidades federativas, conforme se ha incrementado el porcentaje de surtimiento completo de recetas, ha aumentado la satisfacción de los usuarios con el acceso a los medicamentos. CONCLUSIONES: En 2006, más de 50 por ciento de las entidades federativas presentaron altos niveles de surtimiento completo de recetas entre los afiliados al SPS (>90 por ciento). El mayor problema en este sentido se encuentra en los hospitales, ya que sólo 44 por ciento de los usuarios que recibieron una prescripción en los hospitales de los SESA en 2006 obtuvieron el surtimiento completo de sus recetas. Este hallazgo obliga a revisar la política de medicamentos del SPS, que ha privilegiado...

OBJECTIVE: Measure and compare the percentage of prescriptions fully dispensed to persons with and without Popular Health Insurance (SPS in Spanish) who use ambulatory and general hospital services associated with the Mexico State Health Services (SESA in Spanish), and taking into account insurance status. SESA user satisfaction was also measured with respect to access to medication. MATERIAL AND METHODS: Information for the study was taken from four surveys of SESA ambulatory and hospital units that included probabilistic samples with state representativity. Samples of ambulatory units were selected by stratification according to level of care and association to the SPS service network. RESULTS: The findings indicate that the percentage of prescriptions fully dispensed in SESA ambulatory units has improved, reaching approximately 90 percent, especially among those units offering services to persons affiliated with SPS. Nevertheless, these percentages continue to be lower than those of ambulatory units associated with social security institutions. Percentages of prescriptions fully dispensed have also improved in SESA hospital units, but continue to be relatively low. In nearly all states, as the percentage of prescriptions fully dispensed has increased, user satisfaction with access to medication has also improved. CONCLUSIONS: In 2006 more than 50 percent of the states had high levels of fully dispensed prescriptions among persons with SPS (>90 percent). The more significant problem exists among hospitals, since only 44 percent of users who received a prescription in SESA hospitals in 2006 had their prescriptions fully dispensed. This finding requires a review of SPS medication policies, which have favored highly prescribed low-cost medications at ambulatory services at the expense of higher cost and more therapeutically effective medications for hospital care, the latter having a greater impact on household budgets.

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