Effects of the Closing the Gap Pharmaceutical Benefit on Hospitalizations among Indigenous Australians Amal Trivedi, MD, MPH Providence VA Medical Center Brown University School of Public Health

Selected Racial/Ethnic Life Expectancy Gaps in US, New Zealand, and Australia

Policy Efforts to Increase Access to Medications among Indigenous Persons Section 100 provisions (1999) Section 100 provisions (1999) Remote Aboriginal health services Remote Aboriginal health services PBS meds supplied to clients without charge PBS meds supplied to clients without charge Qumax (2008) Qumax (2008) Non-remote ACCHS Non-remote ACCHS Copayment assistance Copayment assistance Funding capped at $11 million; about 20% of clients Funding capped at $11 million; about 20% of clients Closing the Gap (2010) Closing the Gap (2010)

Closing the Gap PBS Copayment Measure Implemented in July 2010 Implemented in July 2010 Applied to all non-remote general practice Applied to all non-remote general practice Reduces monthly medication copayment to $5.40 (from max of ~$35) for non-concessional patients and $0 for concessional Reduces monthly medication copayment to $5.40 (from max of ~$35) for non-concessional patients and $0 for concessional Registration through GP Registration through GP “With chronic disease or at risk for chronic disease” “With chronic disease or at risk for chronic disease”

Closing the Gap PBS Copayment Measure Uncapped Uncapped Estimated to cover 70,000 Indigenous persons at cost of $90 million Estimated to cover 70,000 Indigenous persons at cost of $90 million Most recent data: 182,000 Indigenous patients access the benefit by 2012 Most recent data: 182,000 Indigenous patients access the benefit by 2012

Study Objective Evaluate the impact of the Closing the Gap PBS Copayment Incentive on hospitalization rates of ambulatory care-sensitive conditions Evaluate the impact of the Closing the Gap PBS Copayment Incentive on hospitalization rates of ambulatory care-sensitive conditions

Methods – Data Sources Sentinel Sites Study Sentinel Sites Study 24 total sites across Australia 24 total sites across Australia Included 16 of 24 sites (Queensland, New South Wales, Victoria, Western Australia) Included 16 of 24 sites (Queensland, New South Wales, Victoria, Western Australia) Uptake of PBS Copayment Incentive Uptake of PBS Copayment Incentive

Methods – Data Sources Obtained hospitalization data from each site from 2009 to 2011 (18 months before and 18 months after policy change) Obtained hospitalization data from each site from 2009 to 2011 (18 months before and 18 months after policy change) Included diagnoses; length of stay Included diagnoses; length of stay Study population includes all residents age 15 and older residing in 16 Sentinel Sites locations Study population includes all residents age 15 and older residing in 16 Sentinel Sites locations Approximately 1.7 million persons Approximately 1.7 million persons

Analyses Calculated population rates of admissions and hospital days for ambulatory care-sensitive conditions amenable to chronic drug therapy Calculated population rates of admissions and hospital days for ambulatory care-sensitive conditions amenable to chronic drug therapy Conditions included: Conditions included: Asthma Asthma Chronic Obstructive Pulmonary Disease Chronic Obstructive Pulmonary Disease Congestive Heart Failure Congestive Heart Failure Angina Angina Diabetes Diabetes Hypertension Hypertension Vascular disease Vascular disease

Analyses Age-standardized rates based on population distribution across all Sentinel Sites Age-standardized rates based on population distribution across all Sentinel Sites Population in each Sentinel Site adjusted in each year to reflect area-level annual growth rate for Indigenous and Non-Indigenous residents Population in each Sentinel Site adjusted in each year to reflect area-level annual growth rate for Indigenous and Non-Indigenous residents Confidence intervals derived using Fay-Feuer method assuming a poisson distribution Confidence intervals derived using Fay-Feuer method assuming a poisson distribution

Uptake of PBS Incentive in Sentinel Sites and Rest of Australia

Ambulatory Care-Sensitive Hospitalizations among Indigenous and Non-Indigenous Australians in Sentinel Sites

Uptake of PBS Incentive Across Sentinel Sites High-Uptake Sites (Uptake)Low-Uptake Sites (Uptake) Logan Woodridge, QL (69%)North Lakes, QL (20%) Dubbo, NSW (54%)Campbelltown, NSW (19%) Grafton, NSW (53%)Newcastle, NSW (19%) Bairnsdale, VIC (52%)Brisbane, QL (18%) Geraldton, WA (51%)Dandenong, VIC (11%) Swan Hill/Mildura, VIC (39%)Kalgoorlie, WA (11%) Cairns, QL (26%)East Pilbara, WA (9%) Tamworth, NSW (26%)Derby, WA (1.5%) 2009 Population 317K (17K Indigenous)1.4 million (24K Indigenous)

Ambulatory Care-Sensitive Hospitalizations among Indigenous Australians in High and Low-Uptake Sentinel Sites

Ambulatory Care-Sensitive Hospital Days among Indigenous Australians in High and Low-Uptake Sentinel Sites

Limitations Not causal Not causal Limited to 3 year time window Limited to 3 year time window Area-level analysis Area-level analysis Lack of individual data Lack of individual data Few covariates Few covariates Other policy changes Other policy changes

Conclusions Large disparities in rates of ACS hospitalizations Large disparities in rates of ACS hospitalizations Substantial reduction in chronic ACS hospitalization rates (~45%) among indigenous patients following PBS copayment incentive Substantial reduction in chronic ACS hospitalization rates (~45%) among indigenous patients following PBS copayment incentive Variations in uptake across regions in Australia Variations in uptake across regions in Australia Reductions exclusively observed in areas with high-uptake of the incentive Reductions exclusively observed in areas with high-uptake of the incentive

Implications Australia has implemented innovative approaches to increase access to medications for Indigenous populations Australia has implemented innovative approaches to increase access to medications for Indigenous populations Increased access to prescription drugs may reduce risk of hospitalization among Indigenous Australians Increased access to prescription drugs may reduce risk of hospitalization among Indigenous Australians Hospital reductions are plausible given prior literature, magnitude of uptake, and types of medications filled Hospital reductions are plausible given prior literature, magnitude of uptake, and types of medications filled

Acknowledgments Margaret Kelaher, PhD Margaret Kelaher, PhD Centre for Health Policy, Program and Economics, University of Melbourne Centre for Health Policy, Program and Economics, University of Melbourne Jane Hall, PhD Jane Hall, PhD Australian Department of Health Australian Department of Health Commonwealth Fund Commonwealth Fund

Hospital Offsets from Enhanced Drug Coverage Systematic review of 8 prior studies published by US Congressional Budget Office Systematic review of 8 prior studies published by US Congressional Budget Office Most studies found evidence that increased use of prescription drugs offset spending on hospitalizations Most studies found evidence that increased use of prescription drugs offset spending on hospitalizations 1% increase in drug utilization associated with a 0.2% decline in non-drug medical spending 1% increase in drug utilization associated with a 0.2% decline in non-drug medical spending Offset occurs nearly immediately Offset occurs nearly immediately

Principal Diagnoses of Hospitalizations

Most Common Medications Filled Under PBS Copayment Incentive Atorvastatin Atorvastatin Metformin Metformin Salbutamol Salbutamol Perindopril Perindopril Codeine Codeine Most common conditions: cardiovascular, mental disorders, diabetes, chronic respiratory conditions, pain relief

Ambulatory Care-Sensitive Hospital Days among Indigenous and Non-Indigenous Australians in Sentinel Sites

Trends in Age-Adjusted Ambulatory Care-Sensitive Hospital Days among Indigenous and Non-Indigenous Australians