Impact of removing prescription co-payments on the use of costly health services: a pragmatic randomised controlled trial

Abstract

Objectives To determine whether exempting people (with high health needs and living in areas of high deprivation) from a $5 prescription charge reduces hospital use. Design Two-group parallel prospective randomised controlled trial. Setting People living in the community in various regions of New Zealand. Participants One thousand sixty one people who lived in areas of high socioeconomic deprivation, and either took medicines for diabetes, took antipsychotic medicines, or had chronic obstructive pulmonary disease (COPD). Of the 1053 who completed the study, just under half (49%) were Māori. Interventions Participants were individually randomized (1–1 ratio) to either be exempted from the standard $5 charge per prescription item for one year (2019–2020) (n = 591) or usual care (n = 469). Those in the intervention group did not pay the standard NZ$5 charge, and pharmacies billed the study for these. Participants continued to pay any other costs for prescription medicines. Those in the control group continued to pay all prescription charges for the year although they may have received one-off assistance from other agencies. Main outcome measures The primary outcome was length of stay (hospital bed-days). Secondary outcomes presented in this paper included: all-cause hospitalisations, hospitalisations for diabetes/mental health problems/COPD, deaths, and emergency department visits. Results The trial was under-powered because the recruitment target was not met. There was no statistically significant reduction in the primary outcome, hospital bed-days (IRR = 0.68, CI: 0.54 to 1.05). Participants in the intervention group were significantly less likely to be hospitalised during the study year than those in the control group (OR = 0.70, CI: 0.54 to 0.90). There were statistically significant reductions in the number of hospital admissions for mental health problems (IRR = 0.39, CI: 0.17 to 0.92), the number of admissions for COPD (IRR = 0.37, CI: 0.16 to 0.85), and length of stay for COPD (IRR 0.20, CI: 0.07 to 0.60). Apart from all-cause mortality and diabetes length of stay, all measures were better for the intervention group than the control group. Conclusions Eliminating a small co-payment appears to have had a substantial effect on patients’ risk of being hospitalised. Given the small amount of revenue gathered from the charges, and the comparative large costs of hospitalisations, the results suggest that these charges are likely to increase the overall cost of healthcare, as well as exacerbate ethnic inequalities. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618001486213 registered on 04/09/2018.

Consequences of cost barriers to prescriptions: cohort study in Aotearoa New Zealand

“…This calculation is based on the assumption of causality, which may not be the case. However, the concurrence of our results with those from experimental 14,15 and other observational studies of different designs 22,23 reinforces the likelihood of there being a causal link between lack of access to medication and increased hospitalisations.…”

“…A small randomised controlled trial of the provision of free prescriptions in Aotearoa found similar results to ours; participants who were provided with free medications had a lower rate of hospitalisations (all cause, and for selected conditions), although the primary outcomes of hospital length of stay did not meet conventional levels of statistical significance. 14 This experimental design-albeit on a relatively small samplecoupled with benefits seen in an international article 60…”

Struggling to afford medicines: a qualitative exploration of the experiences of participants in the FreeMeds study

“…18 The government announced its intention to universally remove the $5 prescription charge in July 2023 in the May 2023 budget, 19 informed by the results of the FreeMeds RCT. 15 This qualitative study demonstrates that removal of charges is likely to make a significant difference to the lives of people like our participants: those in areas of high deprivation, with significant health problems. The National/ ACT/New Zealand First coalition government elected later in 2023 said they will reintroduce prescription charges except for people with a SuperGold card or a Community Services card (ie those over 65 or earning a very low income).…”

“…that free prescriptions had a significant impact on hospitalisations. 15 This illustrates one of the on-going day-to-day struggles of those who live in poverty. Findings are similar to our earlier paper, 14 suggesting that although the number of people reporting problems affording medicines may have dropped, 8 the reality for some groups has not changed.…”

“…14 This paper presents the qualitative component of a randomised controlled trial (RCT) of prescription charges (the FreeMeds study). 15 The aim of this qualitative component was to explore participants' previous experiences with paying for medicines, and the impact of receiving free medicines through the study.…”