澳大利亚药物使用的成本障碍:患者体验调查背景分析。

IF 6.7 2区 医学 Q1 MEDICINE, GENERAL & INTERNAL Medical Journal of Australia Pub Date : 2024-09-03 DOI:10.5694/mja2.52427
Narcyz Ghinea
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A survey published in 2023 found that 21.9% of people living in Australia who were aged 45 years or older, and were currently taking prescription medicines, had experienced medication-CRNA at some point in the previous 12 months.<span><sup>7</sup></span> This result is exactly replicated by another independently conducted survey of 11 000 people during the same general period, although the sample in this case was not limited to a specific age group.<span><sup>8</sup></span> By contrast, the ABS’ Patient Experience Survey reports medication-CRNA rates as high as 7.4% (45–54-year-olds) and low as 4.3% (65–74-year olds) for patients aged 45 years and older.</p><p>There are important data that the ABS survey does not collect and is essential to understand. The experience of patients who can only afford their medications by making budget sacrifices that substantially affect their lifestyle is not captured. The aforementioned study of Australians aged 45 years and older found that 17.7% of people taking prescription medications had to take one or more of the following measures to buy their medicines at some point in the previous 12 months: skipping meals, not paying bills, borrowing money, selling assets, getting a loan, or drawing down a mortgage.<span><sup>7</sup></span> Others resorted to importing cheaper medications from abroad via online platforms. A study published in 2019 estimated that out-of-pocket health care expenditure drives hundreds of thousands of Australians into income poverty each year, with 285 000 entering poverty in 2014.<span><sup>9</sup></span> Therefore, the fact patients do find ways to pay for medicines does not mean they are affordable. This is supported by the fact that 30% of Australians consider medications to be unaffordable despite the relatively low rates of medication-CRNA reported by the ABS.<span><sup>8</sup></span></p><p>To support evidence-based policy reform to improve medicine access, more data on medication-CRNA across the entire spectrum of medical services, not only general practice services, are required. We also need to understand how many people are prescribed medicines not subsidised by the Pharmaceutical Benefits Scheme (PBS), which adds an additional cost barrier for patients. This would include taking account of the prevalence and costs of off-label prescribing, which is generally not subsidised by the PBS but is an important part of clinical practice.<span><sup>10</sup></span></p><p>According to the Australian Institute of Health and Welfare, spending on non-PBS medicines represents the largest category of out-of-pocket spending by Australians by far, accounting for about a third of the total.<span><sup>11, 12</sup></span> However, the data do not distinguish between prescription-only and other medications such as vitamins and complementary therapies and so it is difficult to interpret their significance. Nevertheless, based on what we know about the rising cost of medicines,<span><sup>13</sup></span> and the high rate of off-label prescribing (which is generally not PBS-subsidised) in clinical practice,<span><sup>10</sup></span> it is reasonable to assume a large portion of this spending is on prescription medicines until evidence emerges to the contrary. In fact, one of the aims of the Therapeutic Goods Administration's new Medicines Repurposing Program is to improve equitable access to treatment by registering off-label medicine uses of public health value so that they can be subsidised.<span><sup>14</sup></span></p><p>Addressing the affordability of medications is critical for reigning in out-of-pocket spending overall and improving access to medical treatment. 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引用次数: 0

摘要

2023 年 11 月,澳大利亚统计局(ABS)发布了 2022-23 年度患者体验调查数据。1 最新发布的数据显示,许多澳大利亚人难以负担所需的药物,与上一年相比,获得药物的成本障碍有所增加。数据显示,9.4% 的女性(5.5% 的男性)报告在过去 12 个月内曾因费用问题而不遵医嘱用药(medication-CRNA)(即因费用问题而延迟或不开药)。然而,考虑到有 8.4%的妇女(25-34 岁的妇女高达 11.3%)至少有一次推迟看或不看全科医师,2 以及 12.2%的妇女(25-34 岁的妇女高达 20.3%)至少有一次因费用问题推迟看或不看专科医生,3 受药物治疗-CRNA 直接或间接影响的妇女比例会更高。25-34 岁年龄段的人比 75-84 岁年龄段的人更有可能遇到用药-CRNA 问题,因费用问题而推迟看或不看全科医生的可能性是 75-84 岁年龄段的人的 2.7 倍,2 因费用问题而推迟看或不看专科医生的可能性是 75-84 岁年龄段的人的 3.1 倍。对于女性来说,这种差异要明显得多,25-34 岁的女性比 75-84 岁的女性更有可能患上药物-CRNA,是 75-84 岁女性的 3.5 倍,更有可能推迟看或不看全科医生,是 75-84 岁女性的 3.8 倍,更有可能因为费用问题推迟看或不看专科医生,是 75-84 岁女性的 4.8 倍。健康状况也是一个重要因素,健康状况一般或较差的人中有 15%的人经历过用药-CRNA(比健康状况好的人高 2.3 倍),11.8%的人因费用原因推迟看或不看全科医生(高 1.8 倍)。社会经济条件最差的人群推迟就医或不就医的几率几乎是最富裕人群的两倍(插文 2)。他们的数据仅在普通诊所就诊时收集,因此不包括专科医生开出的药物。这是一个重大的空白,因为 42.2% 的受访者需要看专科医生,6 而且我们有理由认为,这些患者中有很多人都会被开一些药。经验证据也支持这样一个事实,即在整个人口和所有就医情况中,经历过药物治疗-CRNA 的澳大利亚人的总体比例要高于澳大利亚统计局的数据显示。2023 年公布的一项调查发现,在澳大利亚生活的 45 岁或以上、目前正在服用处方药的人中,有 21.9% 的人在过去 12 个月中的某个时间点曾经历过药物治疗--CRNA。7 这一结果在同一时期对 11000 人进行的另一项独立调查中也得到了完全相同的验证,尽管这次调查的样本并不局限于特定的年龄组。相比之下,澳大利亚统计局(ABS)的《患者体验调查》(Patient Experience Survey)报告称,45 岁及以上患者的药物滥用率高达 7.4%(45-54 岁),低至 4.3%(65-74 岁)。澳大利亚统计局的调查没有收集到一些重要的数据,而了解这些数据是至关重要的。那些只能通过牺牲预算来支付药物费用,从而严重影响其生活方式的患者的经历没有被记录下来。上述针对 45 岁及以上澳大利亚人的研究发现,17.7% 的处方药服用者在过去 12 个月的某个时间点不得不采取以下一种或多种措施来购买药物:不吃饭、不付账单、借钱、变卖资产、贷款或抵押贷款。2019 年发表的一项研究估计,自费医疗支出每年导致数十万澳大利亚人陷入收入贫困,2014 年有 28.5 万人陷入贫困。尽管澳大利亚统计局(ABS)报告的用药-CRNA 比率相对较低,但仍有 30% 的澳大利亚人认为买不起药,这一事实也证明了这一点。8 为支持循证政策改革以改善药品获取,我们需要更多关于整个医疗服务领域(而不仅仅是全科服务)的用药-CRNA 数据。 我们还需要了解有多少人所处方的药品不受药品福利计划(PBS)的补贴,因为这给患者增加了额外的成本障碍。10 根据澳大利亚卫生与福利研究所(Australian Institute of Health and Welfare)的数据,非 "药品福利计划"(PBS)药品的支出是澳大利亚人自费支出中最大的一类,约占总支出的三分之一。尽管如此,根据我们对药品成本上升的了解,13 以及临床实践中标签外处方的高比例(通常不受 PBS 补贴),10 我们有理由认为,在出现相反的证据之前,大部分支出都用于处方药。事实上,美国治疗用品管理局(Therapeutic Goods Administration)新推出的 "药品再利用计划"(Medicines Repurposing Program)的目的之一,就是通过登记具有公共卫生价值的标示外药品用途,使其能够获得补贴,从而改善公平的治疗机会。此外,我们需要更谨慎地考虑如何使用有限的资源,因为在澳大利亚等高收入国家,50% 以上的药品支出仅用于治疗 2-3% 的患者。2021-2022 年,在政府支出最高的 50 种 PBS 药物中,有 25 种药物的补贴处方不到 6 万张,但政府却为此花费了 37 亿美元,占当年 PBS 支出总额(147 亿美元)的四分之一。16 最后,还有一些人在无形中遭受着用药成本的障碍:患者在与医生讨论成本问题后,医生会给他们开一些劣质药(例如,疗效不如新药但价格更贵的旧药),或者根本不给他们开药。由于没有脚本,有关这种以成本为动机的劣质治疗的书面数据从未被记录下来,但在最新药物价格不断上涨并刷新纪录的时代,这些数据却非常重要,因为患者越来越难以承受这些药物。
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Cost barriers to medication access in Australia: an analysis of the Patient Experience Survey in context

In November 2023, the Australian Bureau of Statistics (ABS) released its 2022–23 Patient Experience Survey data.1 This latest release shows that many Australians struggle to afford the medicines they need and that cost barriers to access have increased compared with the previous year.

Women, younger people and those in poorer health are particularly affected. The data show that 9.4% of women compared with 5.5% of men reported cost-related non-adherence to medications (medication-CRNA) (ie, delaying or not filling scripts due to cost) prescribed by their general practitioner in the previous 12 months.2 The proportion increases for younger women to 14.7% for 15–24-year-olds and to 13% for 25–34-year-olds (Box 1). However, considering that 8.4% of women (and as high as 11.3% for women aged 25–34 years) at least once delayed seeing or did not see a general practitioner,2 and 12.2% (and as high as 20.3% for 25–34-year-olds) at least once delayed or did not see a specialist due to cost,3 the proportion of women directly or indirectly affected by medication-CRNA would be even higher.

Younger Australians are more likely to experience cost barriers to care than older Australians. A 25–34-year-old is 2.7 times more likely to experience medication-CRNA than a 75–84-year-old, 3.1 times more likely to delay visiting or not visit a general practitioner due to cost,2 and 3.8 times more likely to delay visiting or not visit a specialist due to cost.3 For women, the discrepancy is much more pronounced, with 25–34-year-olds 3.5 times more likely to experience medication-CRNA than 75–84-year-olds, 3.8 times more likely to delay visiting or not visit a general practitioner, and 4.8 times more likely to delay visiting or not visit a specialist due to cost.

Health status also plays an important part, with 15% of individuals in fair or poor health experiencing medication-CRNA (2.3 times higher than those in good health) and 11.8% delay visiting or not visit a general practitioner due to cost (1.8 times higher).4 For specialist visits the discrepancy was not as stark.5 The most socio-economically disadvantaged people were also almost twice as likely to delay or not seek treatment than the most advantaged (Box 2).4

The de facto rate of medication-CRNA is necessarily higher than what is reported in the ABS's survey. Their data are collected in the context of general practice visits only, so they would not include medicines prescribed by specialists. This is a significant lacuna since 42.2% of those surveyed needed to see a specialist,6 and it is reasonable to assume many of these patients would be prescribed some medication. The Australians that miss out on seeing a general practitioner or specialist due to cost would not get the chance to be prescribed medication.

Empirical evidence also supports the fact that the overall proportion of Australians experiencing medication-CRNA across the entire population and all medical encounters is higher than the ABS data indicate. A survey published in 2023 found that 21.9% of people living in Australia who were aged 45 years or older, and were currently taking prescription medicines, had experienced medication-CRNA at some point in the previous 12 months.7 This result is exactly replicated by another independently conducted survey of 11 000 people during the same general period, although the sample in this case was not limited to a specific age group.8 By contrast, the ABS’ Patient Experience Survey reports medication-CRNA rates as high as 7.4% (45–54-year-olds) and low as 4.3% (65–74-year olds) for patients aged 45 years and older.

There are important data that the ABS survey does not collect and is essential to understand. The experience of patients who can only afford their medications by making budget sacrifices that substantially affect their lifestyle is not captured. The aforementioned study of Australians aged 45 years and older found that 17.7% of people taking prescription medications had to take one or more of the following measures to buy their medicines at some point in the previous 12 months: skipping meals, not paying bills, borrowing money, selling assets, getting a loan, or drawing down a mortgage.7 Others resorted to importing cheaper medications from abroad via online platforms. A study published in 2019 estimated that out-of-pocket health care expenditure drives hundreds of thousands of Australians into income poverty each year, with 285 000 entering poverty in 2014.9 Therefore, the fact patients do find ways to pay for medicines does not mean they are affordable. This is supported by the fact that 30% of Australians consider medications to be unaffordable despite the relatively low rates of medication-CRNA reported by the ABS.8

To support evidence-based policy reform to improve medicine access, more data on medication-CRNA across the entire spectrum of medical services, not only general practice services, are required. We also need to understand how many people are prescribed medicines not subsidised by the Pharmaceutical Benefits Scheme (PBS), which adds an additional cost barrier for patients. This would include taking account of the prevalence and costs of off-label prescribing, which is generally not subsidised by the PBS but is an important part of clinical practice.10

According to the Australian Institute of Health and Welfare, spending on non-PBS medicines represents the largest category of out-of-pocket spending by Australians by far, accounting for about a third of the total.11, 12 However, the data do not distinguish between prescription-only and other medications such as vitamins and complementary therapies and so it is difficult to interpret their significance. Nevertheless, based on what we know about the rising cost of medicines,13 and the high rate of off-label prescribing (which is generally not PBS-subsidised) in clinical practice,10 it is reasonable to assume a large portion of this spending is on prescription medicines until evidence emerges to the contrary. In fact, one of the aims of the Therapeutic Goods Administration's new Medicines Repurposing Program is to improve equitable access to treatment by registering off-label medicine uses of public health value so that they can be subsidised.14

Addressing the affordability of medications is critical for reigning in out-of-pocket spending overall and improving access to medical treatment. In addition, we need to consider more carefully how limited resources are spent, as over 50% of all pharmaceutical spending in high income countries like Australia is directed towards only treating 2–3% of patients.15 Of the top 50 PBS medicines by government expenditure in 2021–2022, 25 had fewer than 60 000 subsidised prescriptions yet cost the government $3.7 billion combined — a quarter of all PBS spending in that year ($14.7 billion).16

Finally, there are people who suffer invisibly from cost barriers to medications: patients who are prescribed inferior medicines (eg, an older medication that is less effective than a newer but also more expensive medication) or no medication at all after a discussion of costs with their doctor. Since there is no script, written data on this cost-motivated inferior treatment are never captured but are of great importance in an era when medicines prices for the newest drugs continue to rise and break new records, becoming further out of reach for patients.13

Open access publishing facilitated by Macquarie University, as part of the Wiley - Macquarie University agreement via the Council of Australian University Librarians.

No relevant disclosures.

Not commissioned; externally peer reviewed.

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来源期刊
Medical Journal of Australia
Medical Journal of Australia 医学-医学:内科
CiteScore
9.40
自引率
5.30%
发文量
410
审稿时长
3-8 weeks
期刊介绍: The Medical Journal of Australia (MJA) stands as Australia's foremost general medical journal, leading the dissemination of high-quality research and commentary to shape health policy and influence medical practices within the country. Under the leadership of Professor Virginia Barbour, the expert editorial team at MJA is dedicated to providing authors with a constructive and collaborative peer-review and publication process. Established in 1914, the MJA has evolved into a modern journal that upholds its founding values, maintaining a commitment to supporting the medical profession by delivering high-quality and pertinent information essential to medical practice.
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