Evaluation of the relationship between the loss of pharmacy benefits and disenrollment, nonpharmacy medical service utilization, and expenditures of individual enrollees in the Total Health 65 Medicare+Choice health plan

The purpose of this research was to examine the relationship between the loss of pharmacy benefits and disenrollment, nonpharmacy medical service utilization, and medical care costs of enrollees in an M+C plan.; The study used a retrospective pretest-posttest design with a nonequivalent comparison group. Disenrollment, nonpharmacy medical service utilization, and expenditures were studied prior to and following the discontinuation of pharmacy benefits in the intervention group. Changes in voluntary disenrollment rates from the pre to the postperiod were investigated among all plan members. Changes in emergency room visits, physician office visits, hospital discharges, and total expenditures were studied in a continuously enrolled group. Changes in medical expenditures were examined in the continuously enrolled group and several chronic disease subgroups.; The change in voluntary disenrollment rates was statistically different between the intervention and control groups. The intervention group exhibited an increase in disenrollment after the discontinuation of pharmacy benefits. The changes in emergency room visits and physician office visits were also statistically different between the two groups. Emergency room visits increased at a higher rate and physician office visits increased at a lower rate when pharmacy benefits were lost. Neither hospital discharges nor medical expenditures exhibited statistically significant differences. Changes in total expenditures were significantly different between the two groups.; The study concluded that the loss of pharmacy benefits was statistically associated with disenrollment, emergency room and physician office use, and total expenditures. The discontinuation of pharmacy benefits contributed to an increase in disenrollments. A substitution effect between emergency room visits and physician office visits was observed. Since many physician visits occur to obtain prescriptions, the lower rate of increase in physician office visits in the intervention group may have resulted from reduced access to prescription drugs. The simultaneous higher rate of increase in emergency room visits would have ensued from declining patient health in the absence of pharmacotherapies. Given that medical expenditures were not affected by the loss of pharmacy benefits, a plausible explanation for the decrease in total expenditures is the savings of pharmacy costs. The discontinuation of the pharmacy benefit did generate cost savings for the plan.