• Determining the economic value of pharmacist services: A study of the reliability and validity of contingent valuation methods

      Metge, Colleen Jane; Provenzano, George, Ph.D. (1996)
      The intent of this study is to understand the extent to which consumers' are willing to pay to have access to community-based pharmacist services. These services are distinct from the physical skills of dispensing a pharmaceutical product. The contingent valuation method was used to determine consumers' willingness-to-pay (WTP) for these services. Contingent valuation is a survey method that asks individuals to express their WTP for a good or service currently not available and/or not priced in well-functioning markets. A convenience sample of 348 adult, working individuals from four locations around Baltimore city were asked their WTP for five individual pharmacist services and then for a package of all services in hypothetical market scenarios. Consumers were asked their WTP via three payment mechanisms: an out-of-pocket payment, a monthly insurance premium and an annual membership fee payable to a pharmacy of their choice. The survey was administered using a self-administered, computerized interview to obtain WTP bids in dollar terms for community-based pharmacist services. All WTP values for pharmacist services are significantly greater than zero. A two-part estimation model that corrects for the biased estimates of zero dollar bidders, was used to separate WTP bidding behavior into two stages. The first stage separates individuals by their decision to bid for pharmacist services and then a decision about how much to bid conditional on bidding in the first place. The probability of bidding ranged from 0.595 for advice on nonprescription medication to 0.837 for the pharmacists attention to safety when dispensing a prescription medication. Respondents were WTP most to have the pharmacist review the appropriateness of all their medication ($4.76, SD 5.90) and to have all pharmacist services available based on an annual fee ($89.14, SD 161.37). Individuals are more likely to bid if they are non-white and have a positive attitude towards paying and are less likely to bid if they have an income exceeding $50,000/year. Non-whites are WTP significantly more than whites. Tests of starting point bias and the effect of information on WTP bids were not significant. The WTP bids obtained for community-based pharmacist services are subject to rational interpretation.
    • An economic and outcome evaluation of the Pharmaceutical Care Services Program for Maryland Medicaid recipients

      Lai, Li-An Leanne; Speedie, Stuart M. (1996)
      The goal of this research was to determine if the Pharmaceutical Care Services Program (PCSP) significantly changes the utilization and cost of medical services for Medicaid recipients. The University of Maryland Center on Drug and Public Policy (CDPP) has contracted with the Maryland Department of Health and Mental Hygiene (DHMH) to provide pharmaceutical care services for Maryland Medicaid recipients. The main goal of PCSP is to improve the appropriateness and cost-effectiveness of physician prescribing decisions and patient drug use. The program accomplishes this by placing clinical pharmacists in hospital clinics to review drug therapy and provide advice to physicians and counseling to patients. A quasi-experimental pretest and post-test design with three control groups was performed in this study. The subjects who received PCSP and met the study criteria were the study group. The subjects who were Medicaid enrollees and relatively similar to the study subjects in terms of age, sex, hospital, and ACG (ambulatory care group) classification were randomly selected into the control groups by using a multiple computerized matching process. Differences in utilization and cost of medical services between study and control groups were tested for statistical significance. Cost-benefit analyses were then performed from budgetary and societal perspectives by applying a net present value method. The mortality and morbidity productivity loss estimations were specifically addressed as the indirect benefits in this study. Lastly, a sensitivity analysis was performed to test the assumptions (discount rate and wage rate) underlying the analysis. In this study, the utilization and costs comparisons between the PCSP patients and control patients revealed that: (1) PCSP "capped" the total cost of services by holding them constant while the control groups' costs rose sufficiently to create a significant difference between the PCSP and control groups; (2) specialty care physician visits remained stable for PCSP while increasing in the control groups; (3) primary care physician visits remained stable for PCSP recipients while they declined in the control groups; (4) less prescription medication was used in PCSP group than in the control group; (5) while the total cost of prescriptions increased for both groups, the cost of PCSP prescriptions was less than the control group cost; (6) PCSP showed no significant impact on the use of the emergency room and hospitalizations. The cost-benefit analysis illustrates that PCSP saved the Medicaid program $204.32 per patient for the first year intervention and $2,043.20 for the future 10 years from a budgetary perspective. From a societal perspective, PCSP saved society $4,116.01 per patient for the future 10 years period. Theoretically, if PCSP were expanded to serve all Medicaid, adult, non-institutionalized patients receiving drug therapy, the state of Maryland should be able to save as much as $27 million in the next fiscal year from a budgetary perspective. The society should be able to save as much as $259 million in the next fiscal year from both direct and indirect savings.
    • The economic impact of DUR interventions on the pharmacological management of asthma in children

      Raut, Monika Kumar; Stuart, Bruce C. (2001)
      The purpose of the dissertation was to assess the economic impact of a DUR intervention among children enrolled in the Pennsylvania Medicaid program who had overused SA beta2-agonist inhalation drugs. This research expanded on previous work, the base study, titled 'Pennsylvania Medicaid Retrospective Drug Utilization Review Program Improvement of the Pharmacological Management of Asthma in Children Enrolled in the Pennsylvania Medicaid Fee-for-Service Program' conducted by the Center on Drugs and Public Policy, University of Maryland and Pennsylvania Medical Society for the Commonwealth of Pennsylvania, Department of Public Welfare. This base study was descriptive in design and did not include a control group. The dissertation used scientifically controlled research methodologies to assess the base study results and evaluate whether a true DUR intervention effect existed. It used various multivariate techniques designed to control for non-intervention related influences. Four pre/post comparison series designs to address uncontrolled confounders such as regression to the mean, history, and maturation were used. These included (a) a self-controlled historical comparison group design, (b) a historical equivalent comparison group design, (c) a concurrent non-equivalent comparison group design, and (d) a regression discontinuity design. The self-controlled historical comparison group design was a single-group pre/post design that monitored trends in resource utilization among the intervention group in a year previous to the DUR claims review period. The historical equivalent comparison group design was a two-group design that compared the DUR intervention group to a comparison group identified by the same criteria as the intervention group in a year previous to the DUR claims review period. The concurrent non-equivalent comparison group design and the regression discontinuity design were two-group designs that utilized two different methods of analyses to compare the intervention group to a control group in the concurrent period. The end-points of interest were cost of asthma medications, asthma-related hospitalizations, and asthma-related emergency department visits. The study used Pennsylvania Medicaid administrative and prescription claims data for the period July 1997 to March 2000 residing at the CDPP. The robustness of each study design's findings to the base study results was analytically assessed. None of the four scientifically controlled study designs showed a significant positive DUR effect. The base study results were confounded by regression to the mean, history, and/or maturation.
    • Home care following hospitalization of elderly rural patients with chronic diseases: An evaluation of changes in perceived health status on fluctuations in utilization and cost of formal and informal services

      Griggs, Marcella J.; Baldwin, Beverly Ann, 1941- (1995)
      Policy efforts to control costs mean that an appropriate balance between formal and informal caregiving systems must be created, but few studies have examined the costs associated with caring for chronically-ill older adults in their homes. The purpose of this study was to describe changes in perceived health status for patients and caregivers and to evaluate the effects of those changes on the utilization and cost of both formal and informal services in the home. A comparative prospective panel design was used to interview a sample of 21 chronically-ill patients and their 21 primary caregivers on admission to a Medicare-certified home health care agency, at termination of skilled services, and 30 days after discharge. Health status measures included the Sickness Impact Profile, Activities of Daily Living, Instrumental Activities of Daily Living, and Burden of Care. Formal services and costs were evaluated using visits made and charges billed to Medicare and/or Medicaid. Informal services and costs were evaluated using hours of assistance provided with ADLs and IADLs and regional hourly wage rates. The data were analyzed using within-subjects repeated measures analysis of variance procedures. Health status of patients changed significantly across time, with patients who got better showing improved health status but continued difficulty with ADLs and IADLs. Burden of Care did not change statistically over time. Formal service costs were higher for patients who got worse compared to those who got better. Patients received 4.4 mean hours of informal services per day. Intensity of informal services was greater during initial home care services; however, intensity remained the same and did not change for those who got worse. The average cost per patient day was $47 for formal services and $44 for informal services. This study revealed a highly impaired patient group with dedicated informal caregivers spending an average of 31 hours each week helping with ADLs and IADLs in addition to the visits made by formal service providers. The findings from this study have importance for public policy and clinical practice with regard to forging realistic linkages between both the formal and informal support systems as patients move from one provider system to the next.