Dissertations / Theses on the topic 'Reimbursement of drugs'

Thesis (S.M.)--Harvard-MIT Program in Health Sciences and Technology, 2012.<br>Cataloged from PDF version of thesis.<br>Includes bibliographical references (p. 63-67).<br>Over the past ten years there has been increasing public concern regarding the rising costs of pharmaceuticals. Drug expenditure is the fastest growing sector of healthcare costs in the United States. The structure of the U.S. healthcare system allows pharmaceutical companies to freely price their drugs. Then payers decide whether and how to cover these drugs. Payers have at their disposal several utilization management tools, such as tiering and prior authorizations, to steer their members to less costly drugs. However, the ability of payers to implement these tools varies significantly depending on whether the drug is covered under the pharmaceutical benefit / Medicare Part D provisions of healthcare plans or the medical benefit / Medicare Part B provisions. Drugs covered under the pharmaceutical benefit / Part D are distributed via retail pharmacies and, in general, are oral pills. Drugs covered under the medical benefit / Part B are physician administered drugs and, in general, are injectables or intravenous drugs. As pharmaceutical companies increasingly price their drugs at higher and higher levels, payers must take a drug's pricing into account when determining how to cover these drugs. This thesis assesses the role pricing plays in how a drug is covered. Two different classes of drugs were chosen to examine this topic: fixed dose combination (FDC) cardiovascular drugs and intravenous oncologies. FDC cardiovascular drugs were chosen because they are covered under the pharmacy benefit / Part D and are considered to have questionable efficacious value over their individual drug components. Intravenous oncologies were chosen because they are covered under the medical benefit / Part B and represent a highly politicized therapy area. These two therapy areas are illustrative of strongly contrasting classes of drugs. Literature review and public sources were used to obtain prices for the select cardiovascular FDCs and oncologies. Medicare's Formulary Finder was used to obtain the coverage level for the cardiovascular FDCs. This preliminary information showed that the most expensive of the select FDCs, Caduet, has the worst coverage. The literature review suggested that Provenge and Avastin, the most expensive of the select oncologies, had difficulty obtaining coverage. To confirm these results, interviews were conducted with a variety of payers. These interviews focused on what factors went into the coverage decision-making process for cardiovascular FDCs and intravenous oncologies. Interviews were also conducted with an oncologic distributor to determine distributors' impact on price. We hypothesized that price was the driving reason for Caduet's, Provenge's, and Avastin's relatively poor coverage. However, our hypothesis was not entirely confirmed. Payers confirmed that price and contracting were the driving factors for Caduet's relatively poor coverage, but they indicated that the situation was not as simple for the intravenous oncologies. Although price does play a small role in the coverage decision-making process for intravenous oncologies, other factors such as public policies and the unmet need in the therapy area drive coverage decisions more than price. Additionally, payers indicated that they lack the ability to steer members to less costly intravenous oncologies due to the drug acquisition and reimbursement structure of the medical benefit. Consequently, payers are beginning to utilize new techniques such as specialty pharmacies to help control utilization of these products. Also, other organizations such as certain oncologic distributors are attempting to implement cost-effective guidelines for intravenous oncologies. Our results have significant implications for what pharmaceutical companies should be considering when pricing their drugs, and highlight the pricing and coverage issues in the current healthcare system's structure that payers and other organizations are facing.<br>by Drew Cronin-Fine.<br>S.M.

BACKGROUND AND OBJECTIVES: Standard meta-analysis compares two treatments whereas network meta-analysis compares multiple treatments. In light of the increasing number of treatments available, we have seen a shift from using standard meta-analysis towards using network meta-analyses to support regulatory and reimbursement decisions. This thesis (composed of nine separate papers) applied network meta-analysis to a series of real world problems which simultaneously addressed many of these methodological issues while also supporting healthcare decision making. METHODS: In the first chapter, background information on network meta-analysis and outline the rationale for each of the subsequent chapters is provided. In Chapter 2, an applied example is presented where we use FDA Public Summary documents to populate a network meta-analysis of antithrombotic therapies for atrial fibrillation. In Chapter 3, the advantages and disadvantages of rapid network meta-analysis using ClinicalTrials.gov are investigated by re-doing Chapter 3 but only using data available in ClinicalTrials.gov and examining concordance. In Chapter 4, the application of network meta-analysis when events are rare are investigated using an illustrative example investigating the risk of serious infection in biologics. In Chapter 5, the application of network meta-analysis to a complex network – triptans for migraine – are presented where there are a large number of studies and treatments. In Chapter 6 a network meta-analysis which assesses both a benefit and harm and integrates findings using a benefit harm methodology is presented. In Chapter 7, methods to incorporate non-randomized studies into network meta-analysis are investigated using data on riskof myocardial infarction derived from the Mini-Sentinel distributed data network. FINDINGS AND CONCLUSION: Pragmatic research around methodological areas in network meta-analysis were conducted to address real world problems for decision makers. It is my hope that this thesis and the approaches used in this thesis for the application of network meta-analysis will be disseminated to enhance research capacity in conducting network meta-analysis in Canada.

Dans le but d’améliorer l’accès au traitement pour les patients souffrant des maladies rares, les gouvernements de certains pays ont mis en place une législation ‘orpheline’ dont le but est d’aider à promouvoir la recherche dans ce secteur. En conséquence, le nombre de médicaments orphelins approuvés a significativement augmenté et continue de croître. Cependant, beaucoup de questions restent encore sans réponses. Les coûts par patients élevés, le manque de connaissance sur les maladies, et d’autres spécificités des médicaments orphelins font obstacle à l’utilisation de méthodes d’évaluations standards. L’objectif de cette étude est d’identifier les critères qui permettraient de déterminer la valeur des médicaments orphelins et les préférences de la société vis-à-vis de ces critères.Dans la première phase de l’étude, un état de l’art du marché des médicaments orphelins a été mené. Les défis associés tant à la recherche &amp; développement qu’à l’évaluation des médicaments pour les maladies rares ont été décrits et classifiés. Une revue de toutes les autorisations de mise sur le marché pour les médicaments orphelins en Europe, ainsi que du marché des médicaments orphelins en France, en Italie, en Angleterre et au Pays de Galles a été réalisée. La disponibilité des médicaments orphelins, leur prix et leur remboursement, ainsi que les détails de l’évaluation par les autorités de santé ont été analysés.Dans la seconde phase de l’étude, une revue de littérature a été effectuée afin d’identifier les déterminants potentiels de la valeur des médicaments orphelins. L’impact de certains de ces attributs - dont le choix a été fait en fonction de la disponibilité des données - sur les prix des médicaments orphelins en France, en Italie, en Angleterre et au Pays de Galles a été exploré à l’aide d’une analyse de régression.Enfin, une enquête en ligne a été menée auprès d’un échantillon représentatif de la population française, afin d’étudier ses préférences relatives à certains attributs, sélectionnés au préalable. La liste de déterminants a été développée en se fondant sur un groupe de discussion et des interviews avec des experts. La méthode de l’enquête a suivi la structure d’un questionnaire à choix discrets et a permis d’estimer les poids relatifs des déterminants étudiés.L’étude a permis d’identifier les caractéristiques des médicaments orphelins qui sont le plus appréciées par la société. Ces résultats pourraient être pris en considération dans la méthode d’évaluation des médicaments orphelins, afin de la rendre plus transparente et robuste<br>In order to improve the access to treatment for patients suffering from rare diseases, the governments of several countries put in place specific ‘orphan’ legislation aiming at promoting research in the field. In response to these measures, the number of approved orphan drugs has dramatically increased and continues to grow. Nevertheless, a number of issues remain unresolved. Thus, high per-patient costs, poor knowledge of the diseases and other specificities of medicines for rare diseases make it impossible to apply standard methods of health technology assessment to orphan drugs. The objective of the present research was to identify the criteria that determine the value of orphan drugs and study public preferences regarding these criteria.In the first phase of the research, a detailed review was conducted of the current situation on orphan drug market. Challenges related to the development and appraisal of orphan drugs were described and catalogued. A review was carried out of all approvals of orphan drugs in Europe, as well as of orphan drug markets in France, Italy and England and Wales. Orphan drug availability, price and reimbursement status, as well as the details of assessment were analysed.In the second phase, a literature review was conducted to identify potential determinants of orphan drug value. The impact of some of these determinants (choice was based on the availability of data) on orphan drug prices in France, Italy and England and Wales was then explored in a regression analysis.Finally, preferences of French general population in relation to the most relevant determinants of orphan drug value were analysed using an online survey. The list of determinants was developed based on a focus group and expert interviews. The survey was designed as a discrete choice experiment and allowed estimating relative weights of the included determinants.The study allowed identification of orphan drug characteristics that are most valued by the society. Its results may be taken into consideration in drug appraisal process in order to enable a fair assessment and pricing of orphan drugs

Le développement de novo de médicaments est un processus long et coûteux. De plus en plus, les développeurs de médicaments cherchent à mettre en oeuvre des stratégies rentables et à moindre risque pour le développement de produits pharmaceutiques. Le processus de trouver de nouveaux usages pour des médicaments existants en dehors de l'indication initiale pour laquelle ils ont été initialement approuvé est couramment désigné comme « repositionnement », « réorientation » ou « reprofilage ». Le développement de formulations différentes pour un même médicament pharmaceutique est communément désigné comme « reformulation » et le processus de trouver une autre utilisation thérapeutique d'un médicament déjà connu est dénommé « repositionnement ». Ces deux stratégies sont devenues un courant dominant dans le développement des médicaments. Les principaux objectifs de la recherche menée dans cette thèse sont de parvenir à proposer une nomenclature et la taxonomie solide et valable pour l'identification et la classification des stratégies de « repurposing » de médicaments ; évaluer les voies de régulation de stratégies de repositionnement et de reformulation, par types de stratégies et dans les 2 régions géographiques étudiées ; et déterminer les paramètres qui ont un impact sur la probabilité d'un résultat positif sur le prix, le remboursement et l'accès au marché vis-à-vis des conditions accordées pour le médicament original dans les deux régions géographiques dans l'étude<br>De novo drug development is a costly and lengthy process. As a result of such market forces, drug developers are increasingly striving to find cost effective and reduced-risk strategies for developing drug products and to protect existing products from competition, as well as to extend their patent protection time. The process of finding new uses for existing drugs outside the scope of the original indication for which they were initially approved is variously referred as repositioning, redirecting, repurposing, or reprofiling. The development of different formulations for a same pharmaceutical drug is commonly designated as “reformulation” and the process of finding a new therapeutic use for an already known drug is referred to as “repositioning”. Both strategies have become a mainstream in drug development. The main objectives of the research conducted in this thesis are to propose a robust and valid nomenclature and taxonomy for identification and classification of drug repurposing strategies, to evaluate which regulatory pathways and trends are taken by drug repositioning and reformulation, by repurposed types and within the Europe and the US and determine which parameters have the most and least impact on the probability of a successful outcome on pricing, reimbursement and market access in repurposing vis-à-vis the conditions granted for the original drug

The objective of my thesis is to summarize activities realted to pricing of drugs, describe ways of launching drugs in the Czech market, present the pricing policy in various stages, forms of price regulation and ways of setting prices and reimbursement. The thesis provides information about steps and issues in the pricing policy by reviewing the existing situation.

The aims of this thesis were to identify whether justification can be provided for the specialized consideration of drugs for rare diseases (DRDs) within reimbursement decision-making, to understand the processes applied for making coverage decisions for DRDs, and to identify how funding outcomes may differ based on the evaluation process used. The characteristics of DRDs were considered in the frame of developing an ethically acceptable rationale for the differential consideration of DRDs within coverage decision-making. The results revealed that the differing evidence base might provide ethical justification for a specialized process, but this does not justify the use of differential funding criteria. A review of processes applied internationally and within Canadian provinces and territories demonstrated that 13 out of 59 processes consider DRDs distinctively. Finally, two case studies of DRDs, Alglucosidase alfa and Canakinumab, were considered to provide insight into the application of different drug reimbursement processes and associated funding outcomes. The results highlight the heterogeneity in funding outcomes for DRDs, which arises through the application of different funding outcomes. While currently processes exist for the evaluation of DRDs and drugs in general, limitations exist with current approaches. Processes should aim to be fair and jurisdictions should carefully consider the justification underpinning a dedicated process for DRDs.

L’objectif de ce travail était d’analyser de manière conjointe différents indicateurs d’abus, de dépendance et de détournement de médicaments psychoactifs en conditions réelles d’utilisation issus de sources de données hétérogènes afin d’en présenter une vision synthétique. Les sources de données utilisées dans ce travail sont issues des outils et programmes des Centres d’Evaluation et d’Information sur la Pharmacodépendance – Addictovigilance (CEIP-A). Elles permettent de mesurer directement l’abus auprès de populations spécifiques de patients dépendants ou sous traitement de substitution par l’enquête OPPIDUM (Observation des Produits Psychotropes Illicites ou Détournés de leur Utilisation Médicamenteuse). Ces outils permettent aussi de mesurer le détournement via la mesure du nombre d’ordonnances falsifiées par l’enquête OSIAP (Ordonnances Suspectes, Indicateur d’Abus Possible) ainsi que la mesure du phénomène de « Doctor Shopping » (chevauchement d’ordonnances) et la mesure du nombre de patients présentant des comportements déviants (issu d’une analyse de classification) à partir de bases de données de remboursement de l’assurance maladie. Cette approche multi-sources a d’abord été appliquée à l’analyse de l’importance du détournement d’usage du clonazépam (Publication n°1). Ce travail a permis de mettre en évidence le détournement émergent du clonazépam et a surtout permis d’illustrer les difficultés à faire émerger cette information de manière cohérente et standardisée au travers des différentes sources de données. Ensuite, l’un des pré-requis d’un système de surveillance de l’abus et du détournement de médicaments étant de permettre d’étudier des tendances évolutives, nous avons proposé la méthode de classification visant à établir des profils de sujets déviants de manière à analyser l’évolution de détournement d’usage de méthyphénidate sur quatre années (Publication n°2). Cette méthode de classification a par la suite, été appliquée de manière conjointe à une méthode de mesure du « Doctor Shopping » pour étudier le détournement d’usage de la Buprenorphine Haut Dosage (BHD) dans la région PACA-Corse (Publication n°3). Cette étude nous a non seulement permis de mettre en évidence un problème important de détournement d’usage de la BHD mais elle nous a permis aussi de montrer la concordance entre ces deux méthodes (mesure du « Doctor Shopping » et méthode de classification) et d’évaluer leurs apports respectifs pour la surveillance de l’abus des médicaments. Ces deux méthodes ont par la suite été analysées de manière conjointe aux données issues des enquêtes OPPPIDUM et OSIAP pour permettre d’étudier et de comparer le détournement d’usage des médicaments de la famille des benzodiazépines (Publication n°4) et des opioïdes (Publication n°5). Cette approche multi-sources permet de limiter les biais inhérents à chaque méthode ou source prise isolément. L’ensemble de nos travaux met en exergue la pertinence d’un tel système pour évaluer l’abus d’un médicament mais aussi pour le comparer à d’autres substances. Néanmoins, le développement d’un tel système appliqué au domaine de la pharmacodépendance est relativement nouveau, et nécessite des améliorations tant dans l’intégration d’autres sources de données, que dans la méthodologie employée pour intégrer et synthétiser l’information ainsi obtenue. Finalement, cette thèse a montré que les CEIP-A avaient le potentiel pour mettre en œuvre un système multi-sources pouvant apporter une réelle contribution à l’étude de la pharmacodépendance en France<br>The objective of this work was to analyze abuse, dependence and diversion of psychoactive medicines in real settings using jointly different indicators issued from mixed datasources in order to present a synthetic vision. The datasources used in this work are issued from the tools developed by the Centres for Evaluation and Information on Pharmacodependency (CEIP). They allow to measure directly drug abuse with specific populations of dependent patients or under opiate treatment (OPPIDUM (Observation of the Illicit Psychotropic Products or Diverted from their Medicinal Use) survey)). These tools also allow to measure the diversion via the measure of the phenomenon of “doctor shopping” (overlapping of prescriptions) and the measure of the number of patients presenting a deviant behaviour from general health insurance databases; then they measure diversion through falsified prescriptions presented at pharmacies (the OSIAP (Forged prescriptions indicating potential abuse) survey).This multisources approach has been firstly applied to analyse abuse and diversion of clonazepam (1st publication). This study has highlighted the emerging problem of diversion of clonazepam, after flunitrazepam and has also illustrated the difficulty of analysing with consistency the information gathered by these different datasources. A good system for controlling drug diversion and abuse has to allow analysing trends. We have so proposed a classification method aiming at revealing profile of subjects with deviant behaviour to use it on an evolutive manner so as to study diversion of methylphenidate on a four year period (2nd publication). This classification method has then been applied jointly with a method measuring the “doctor shopping” to analyse diversion of High Dosage Buprenorphine (HDB) (3rd publication). This study has revealed an important problem of diversion of HDB, has also demonstrated that the two methods were globally concordant and has allowed to evaluate their advantages for the controlling of the abuse and diversion of prescription drugs. These two last methods have then been analysed jointly with data from the OPPIDUM and OSIAP surveys to allow to study and compare diversion of benzodiazepine drugs (4th publication) and opioids drugs (5th publication). This multisource approach allows to limit biases linked to each method seen individually. Our work points out the relevance of such a multisources system to estimate the abuse of a prescription drug and to compare it with the other substances. Nevertheless, the development of such a system applied to the domain of the drug dependency is relatively new, and requires improvements concerning the integration of the other sources of data and the methodology used to join and synthetize the information obtained. Finally, such a system "multi-sources” has the potential to exist and to make a real contribution to the domain of the drug dependency in France

碩士<br>國立陽明大學<br>藥理學研究所<br>98<br>Peptic ulcer diseases (PUD) are the most common gastrointestinal (GI) diseases. The prevalence of chronic peptic ulcer was about 10% in the total population. Bureau of National Health Insurance (NHI) work out strict reimbursement guidelines due to anti-ulcer drugs are expensive. An NHI policy has changed for the prescription of anti-ulcer drug since October 1, 2003, in which an upper GI endoscopy must be done prior to prescribing anti-ulcer drugs with prices is above 4 NT dollars. The presented study used NHI outpatient claims database and examined the influences of this changing policy on prescription patterns with related problems of GI drugs in peptic ulcer diseases between January 2002 and December 2005. This study analyzed the level of hospital, registered divisions, and indications from these prescription items. Result: (1) The upper gastrointestinal endoscopy exams performed within in the PU drug prescriptions had increased 17% and the volume of H2RA which price is above 4 NT dollars group increased 8%. (2) Prescriptions containing anti-ulcer drugs with prices under 4 NT dollars were increased in district hospitals (43%) in 2004. Most the H2RA prescriptions (above 90%) were prescribed in physician clinics and dental clinics. (3) Defined daily doses were increased 54-60% in non-gastrointestinal clinics than in gastrointestinal clinics. DDDs of gastrointestinal and non-gastrointestinal clinics increased 66% and 15% from 2003 to 2004. (4) In the non-gastrointestinal clinics, most prescriptions contributive to DDDs were registered to rea-nose-throat clinics, and the increasing ratio of DDDs was contributed by chest medicine clinics. The amount of an anti-ulcer drug prescribed with indications increased 14.8% in 2004, and DDDs increased 32% in the lower price group (under NT 4 dollars). DDDs increased 13% in the off-label-use group, and 10% in the lower price group (under NT 4 dollars). (5) The more DDDs increased in regional hospitals the higher prevalence of potential drug-drug interactions (DDI) occurred with. Generally no matter drugs prescribed with indications or non-indications, DDDs increased due to the increasing DDDs in regional hospitals accompanied with higher prevalence of potential drug-drug interactions, health care authorities should clearly define the health insurance reimbursement guidelines for anti-ulcer drugs for off-label use. Health care authorities should also provide other H2RA (under 4 NT dollars) to avoid severe DDIs such as cimetidine, and promote to development of DDI-Intercept system for medication safety.

碩士<br>國立臺北大學<br>企業管理學系<br>105<br>The purpose of this research is to investigate the relationship between the volume of clinical studies and the volume of sales of specialty drugs and common chronic diseases drugs after NHIA (National Health Insurance Administration) reimbursement. For specialty drugs, two Epidermal Growth Factor Tyrosine Kinase Inhibitor(EGFR-TKIs), Iressa and Tarceva for Adenocarcinoma were selected and for common chronic disease, three Statins for hyperlipidemia were selected in this research. We analyzed the relationship between the volume of clinical studies published and their volume sales after reimbursement. The results showed that for specialty drugs, EGFR-TKIs, the volume of clinical studies was significantly correlated with the volume sales(r=0.722, p=0.000) but we found no correlation(r=0.189, p=0.376) for common chronic disease drug Statins .Although there are a lot of limitations of this research, our research suggested that pharmaceutical companies should continue to invest resources in conducting Phase IV clinical studies particularly for specialty drugs, not only for generating evidence for physicians to guide their clinical practices but also generate more consumptions and revenue by expanding more patients suitable for the medications with substantial evidence support.

Relatório de Estágio do Mestrado Integrado em Ciências Farmacêuticas apresentado à Faculdade de Farmácia<br>Os medicamentos órfãos são um assunto de importância crescente para os responsáveis pelas políticas de saúde na Europa. O sucesso do Regulamento Europeu dos Medicamentos Órfãos resultou num notório aumento do número de medicamentos órfãos com Autorização de Introdução no Mercado (AIM) e muitos outros medicamentos em desenvolvimento receberam a designação de medicamento órfão. Contudo, a sua disponibilidade nos diferentes Estados-membros da UE permanece desigual uma vez que as decisões de reembolso são realizadas a nível nacional.Por um lado os orçamentos limitados dos governos nacionais faz com que o preço elevado destes medicamentos seja uma barreira ao seu acesso. Por outro lado, a falta de evidência clínica robusta acerca da sua eficácia faz com os organismos de Avaliação de Tecnologias de Saúde (ATS) tenham dificuldades e incertezas na previsão da eficácia e custo-efetividade dos medicamentos órfãos no mundo real e, consequentemente, na tomada de decisão sobre o seu financiamento. Existe uma clara tendência para o crescimento do mercado dos medicamentos órfãos e para a contínua aposta na I&D nesta área, o que representa uma grande esperança para os doentes. Assim, visto que a tendência será o aumento do número de medicamentos órfãos, é essencial que o seu acesso seja célere e igual para todos os doentes. Existe então a necessidade de uma maior colaboração entre os diferentes stakeholders e de uma abordagem transparente, com os mesmos critérios de avaliação, entre os Estados-membro da UE.<br>Orphan drugs are an increasingly important issue for health policymakers in Europe. The success of the European Regulation on Orphan Medicinal Products resulted in a notable increase in the number of orphan medicinal products with marketing authorisation and many other medicinal products under development were designated as an orphan medicinal product. However, their availability in different EU Member States remains unequal as reimbursement decisions are made at national level. In one hand, the limited budgets of national governments make the high price of these medicines a barrier to their access. On the other hand, the lack of robust clinical evidence about its efficacy makes that Health Technology Assessment (HTA) organisms have difficulties and uncertainties in predicting the effectiveness and cost effectiveness of orphan drugs in the real world and consequently in decision-making on their reimbursement. There is a clear trend towards the growth of the market for orphan drugs and the continued focus on R&D in this area, which is a great hope for patients. Thus, since the trend will be the increase of the number of orphan drugs, it is essential that their access to be rapid and equal for all patients. Thus, there is a need for greater collaboration between different stakeholders and a transparent approach, with the same evaluation criteria, between EU Member States.

碩士<br>中國醫藥大學<br>醫務管理學系碩士在職專班<br>98<br>Abstract Purposes： This project aims to investigate the impact of drug reimbursement policies on prescription of patients with hypertension. The analytic parameters include average daily medical expenses, average number of medicines, and switch to generic medicines percentage. Methods: The database is from National health Insurance Research databases of National Health Research Institute. It composes of detail information of medical expenses and prescription orders from 200 thousands persons. The data before the adjustment of drug reimbursement policies were from period between January 1, 2006 and October 30, 2006; the data after the adjustment of drug reimbursement policies were from period between March 1, 2008 and December 31, 2008. Average daily medical expenses, average number of medicines, and generic drug substitution percentage between these two time periods were compared respectively. Results: There were 7051 patients, of which 46.49% were male and 53.51% were female. The average age was 65.13 year. The differences of Average daily medical expenses, average number of medicines, and generic drug substitution between these two periods were statistically significant. Patients with severe disease status and patients at medical centers had higher daily medical expenses. The average number of medicines was related to gender, medical center and public hospital ownership; generic drug substitution was more frequent in clinics, and more in southern area. The multilevel analysis showed that daily medical expenses was related to disease severity and private medical center. Number of drugs was higher in medical center and the percentage of generic drug substitution was higher in clinics. Key word：medical expenses, drug reimbursement policies, generic drug substitution

碩士<br>國立交通大學<br>高階主管管理學程碩士班<br>91<br>ABSTRACT The National Health Insurance Program was implemented in March 1, 1995 and this program covers 96% of population in October 31, 2002. According to the statistic data, 24.8 percent of medical treatment payment is the expenditure of drug. The causes for growing up of expenditure of drug including the increasing need for medical treatment from people, the need for upgrading the quality of medical treatment, aging of the population, change of nature of disease… etc. However, the drug reimbursement system still has some problems to induce the topic of ‘Black Hole of Price of Drug’ to be widely discussed over and over again. This study method is referred to the drug imbursement system in developed countries such as British, Japan, Unites States of America and Canada, and by using the questionnaire to interview with local related businesspeople, scholars, professionals and patients. The results are concluded and selected for five drug reimbursement systems. Based on the AHP method to build up Taiwan’s ‘Evaluation Structure Diagram for Schemes of National Health Insurance Drug Reimbursement System’. Then adopt Fuzzy MCDM to precede the practical study and evaluation on the Schemes of National Health Insurance Drug Reimbursement System. The purpose of this study is to select the most suitable scheme for National Health Insurance Drug Reimbursement System to attain the following four targets. 1. To accomplish the drug reimbursement strategy of government 2. To meet the expectations of medical treatment providers 3. To satisfy the requirements of customers 4. To meet the business planning of suppliers of pharmaceutical products’ The results of study will be offered to National Health Insurance related decision-making department for reference to draft the drug reimbursement system. The results and suggestions of the study: 1. The sequence of importance for four category’s aspect: The most important is ‘To meet the expectations of medical treatment providers’, then ‘To satisfy the requirements of customers’, ‘To accomplish the drug reimbursement strategy of government’ and the last is ‘To meet the pharmaceutical products suppliers’ business planning’. The deviation of balancing weight of these four aspects is little and the importance is very similar. 2. According to score of the average effective value of drug reimbursement system, which is evaluated and selected by whole interviewers, the sequence from large to small is ‘System of drug effect comparison’, ‘System of Drug Price Reference’, ‘System of Cost Structure’, ‘System of Drug Price Baseline’, ‘System of Global Budget’. 3. It does not meet the expectations from government (insurer), providers of medical treatment, customers and suppliers of pharmaceutical products if there is only one drug reimbursement system. The Bureau of National Health Insurance should based on the key point to select ‘System of Drug Price Reference’ as the basis to evaluate the drug reimbursement system and combine with other drug reimbursement systems. 4. The ‘System of Cost Structure’ is not suitable to adopt at current stage. 5. ‘Global Budget for Drug Reimbursement’ is independent from ‘Total Budget for Medical Treatment Reimbursement’. Any manners for Drug Reimbursement System of National Health Insurance that conducted by Bureau of National Health Insurance should consider the privilege of people’s health. The people should avoid to be exposed to the risk of using unknown medicines. Meanwhile, the expenditure of medical and drug should be reasonable to reduce the financial burden of government. Thus the National Insurance can be run forever.

Purpose: To estimate the willingness and ability of private plans to manage costs during the generic drug procurement reform era that began in 2006 in Canada. Two cost management aspects were assessed; the prices paid for generic drugs and the extent to which private plans have enacted measures to increase generic substitution. Methods: IMS-Brogan Pharmastat data was used to estimate the price of commonly prescribed generic drugs and generic share of prescriptions, by plan type, province and quarter from 2003 to 2012. Results: Prices did not decline unless the provincial governments mandated the reductions. Savings from this mandate was approximately $264 million in Ontario. Rates of generic substitution were unaffected by the price reductions, possibly because the rates were high beforehand. Conclusion: Private plans did not independently obtain lower generic prices. Due to already high substitution rates, there may have been limited potential for additional savings from mandatory substitution controls.

碩士<br>中山醫學大學<br>醫學研究所<br>93<br>Background: National Health Insurance (NHI) Program has been launching for more than a decade, in which the drug expenditure has always been a large financial burden to Bureau of National Health Insurance (BNHI), from 62.1 billion in 1996 up to 80.4 billion in 1999. The growth rates at 1998 and 1999 even reached to 12.9% and 11.3% respectively. In view of the drastic increase in drug expenditure and its growth rate, BNHI in 1999 announced a drug reimbursement adjustment policy for drug utilization and expenditure aiming at controlling the drug expenditure to a reasonable level. Eventually, the expenditure on drug utilization has been decreasing from around 7% in 2000 to 3.1% in 2001, and then to 2.2% in 2002. Although the drug expenditure has been dropped to below 3%, the underlying factors controlling the growth are still unknown. The influence of the reimbursement adjustment policy on different levels of health care organizations has yet been studied. Therefore, the primary objective of this thesis is to analyze in-depth the utilization and expenditure of drug in between January 2000 to December 2002, three years of time when the new policy has been launched. Then, recommendations are inferred from the findings to improve the monitoring of the drug expenditure and medical care. Materials and methods: Data being analyzed is obtained from the BNHI, starting from January 2000 to December 2002. The data is basically the detail break-down expenditures the health organization units submitted to BNHI for reimbursement. In which, the data not only provides the information about the total amount of drug expenditure within the organization, but also provide detail information regarding the expenditures in different period of time, different levels and different departments, such as in-patient departments (IPD) and out-patient departments (OPD). Not all kinds of drug are studied in the thesis. Only the top 1000 drugs out of about 4000 drugs ranked by their total expenditures within the period of study will be selected, which have already constituted over 70% of the total amount on drug expenditure. Their trends are thus analyzed by using one-way ANOVA in different dimensions including by different levels, by AHFS and by in/out-patient departments. Results: Within the period of study, it is found that (1) the expenditures of all 19 categories of drugs in accordance with AHFS categorization are increasing. The expenditure in curing heart blood vessel is the largest. (2) By analysis the expenditure in different levels, it is also found that the drug expenditure in curing blood vessel is the largest in all 4 levels. (3) By different levels of health care organizations, the drug expenditure in curing heart blood vessel is the top in medical centers & regional hospitals while the drug expenditure in curing intestine is the top in district hospitals & clinics. Conclusions: (1) The drop of the expenditure in Vitamin should be due to the imposing of the reimbursement adjustment policy. (2) Observe a large amount of expenditure in anti-infection medicine in medical center, regional & district hospitals, it seems that infection has been an inevitable problem in hospital. A better monitoring system for infection control seems to be a topic to be concerned. (3) It is an alarm to our citizen that the expenditure of drugs for curing blood vessel is increasing. It seems necessary to have a campaign to promote the health care on heart diseases. (4) The proportional of the unclassified drugs is persistently in high level. Re-categorization should be done in the future.

碩士<br>臺中健康暨管理學院<br>健康管理研究所<br>92<br>The Bureau of National Health Insurance paid about 70 billion NT dollars per year for drugs for outpatients, which accounted about one-fourth of the total medical expenses, and brought a very great effect to the financial condition of the national health insurance program. This project is to study the feasibility of having the outpatients to buy drugs by themselves without cost sharing by referring to the policies adopted in the advanced nations. The purposes of the study are: (1) reviewing the payment for drugs and the payment system in the advanced nations with social medical insurance or national health care programs; (2) discussing the effect of readjusting out-patients to purchasing the drug by themselves like Canada to the Bureau of National Health Insurance, the public, and the hospital medical and pharmaceutical industries; and (3) evaluating the feasibility of such a change from the Bureau of National Health Insurance, the pharmaceutical industry, medical care providers and the public.（4）the results are discussed to provide a reference for determining the policy in the national health insurance program. In addition to review on literatures published by some international publications, the study mainly include analysis on the Bureau of National Health Insurance, the public and the medical care/drugs providers for a feasibility that can benefit all of them. First, descriptive analysis is used first by referring to the data about medical expenses applied by the contracted hospitals and clinics under the National Health Insurance data base during 2001 September to December in order to review the effect of such change to the financial condition of the Bureau of National Health Insurance, the change the medical care providers’ income in different diseases and in different classes of hospital/clinic, and the change on financial burden of the public. Second, the insured, medical and pharmaceutical industry’s degree of acceptance to this change is then discussed by questionaire method. Finally, the data are sorted and the results are discussed to provide a reference for determining the policy in the national health insurance program.

碩士<br>國立高雄應用科技大學<br>高階經營管理研究所碩士在職專班<br>101<br>The research results show that the relationship quality and perception of product innovation have significant effects on physician’s prescribing intention of new drug. The reimbursement of new drug moderates the effects of the perception of product innovation on physician’s prescribing intention of new drug. But it doesn’t moderate the effects of the relationship quality. We also find that the influences of the constructs, commitment, rewards and trust, of relationship quality on physician’s prescribing intention of new drug are significant. However, the physicians are found to actually adopt the perception of product innovations with significant complexity, observability, compatibility and relative advantage. These findings also have implications for new drug adoption. Our findings provide the following recommendations. First, strengthen the physician’s acceptance and understanding of new drug. Second, the pharmaceutical or company should expand the means of new drug’s marketing to pursuit the product innovation. Third, the establishment of a high relationship quality will increase the physician’s satisfaction and loyalty to improve his prescribing intention of new drug. Results of this study will provide the references to pharmaceutical industry development strategy and management of marketing decision study.

碩士<br>長榮大學<br>醫務管理學研究所<br>94<br>Facing the impending DRG payment system, hospitals must try to control medical expenses to reduce financial risks, and make sure services are provided in a cost-effective way. For each specific DRG, the differences of medical expenses are influenced mainly by doctors'' medical behaviors. However, doctors usually need to make medical decisions within a short period of time. Therefore, this study aimed to develop a decision support system to help monitor inpatient services'' financial risks under the DRG payment system. It''s expected that not only may the decision support system help quantify probable financial risk of each DRG service quickly and precisely, but also will propose appropriate approaches to reducing financial risk through identification of problematic expense items. This study developed the decision support system of its own, which used Visual Basic 6.0 as the front-end system developing tool and Microsoft Access 2003 as the database management system under Windows XP. The financial risk assessment mechanism uses claims data as modeling base of a regional teaching hospital''s inpatient services between 2002 January and 2004 July (37,031 cases). Based on the Bureau of National Health Insurance''s second version DRG coding algorithms, the system converses ICD-9 codes into DRGs and computes corresponding reimbursement fees. Then, it computes the difference (ΔR) between actual medical expense (R'') and DRG reimbursement (R), and calculates the ratio of the difference to the DRG reimbursement (ΔR/R), which serves as the comparison basis among doctors and between any doctor of interest and the benchmarker. Briefly, when ΔR is positive, it means the service provided generates profits; otherwise, it incurs a loss. The proposed decision support system is expected to help doctors better understand what the financial risk might be for any specific DRG service. It provides doctors with financial risk indicators and corresponding expense items based on historical data to serve as reference for potential expense control. After admitting a patient, the doctor proceeds query analysis by inputting a DRG code and his/her doctor ID code, and then the system will generate relevant information such as hospital-wide all-DRGs inpatient financial risk, and financial risks for specific DRG, or specific doctor of concern and his/her benchmarkers (99th percentile, 75th percentile, and 50th percentile). Relevant suggestions of potential expense control are provided. The developed system is expected to improve the concept of financial risks for health care providers. It is also expected to reinforce the expense control mechanism through the direct participation of health care team members in financial risks monitoring activities.

碩士<br>長榮大學<br>醫務管理學系碩士班<br>93<br>As the health insurance expenditures keep rising, all countries are facing the pressure of losing the financial balance on health insurance; therefore, the payment system reforming mechanisms have come into being, such as Global Budget and DRG payment system so as to hold back the medical expenditures. In order to control effectively the medical expenses and allocate reasonably the limited health services resources, the NHI has been phasing in the Global Budget system step by step, and will launch the Diagnosis Related Groups (DRGs) payment system for the inpatient services. To assess the financial risks hospitals will be taking after the implementation of this DRG payment system, this study is to compare the actual medical fee with DRG fixed fee (R), take the difference （ΔR） between the two fees, and calculate the difference to fixed fee ratio for each DRG patient （ΔR/R）. Briefly, the main purposes of this study are to compare the financial risks of medical treatment across clinical departments and major disease category (MDC), and make comparisons on the financial risks across physicians within specific MDC and DRG. This study uses insurance claims data from the National Health Insurance prepared by a regional teaching hospital located in the southern Taiwan. All the inpatient services excluding psychiatric (MDC19 ＆ MDC20) and cancer cases within the time period of July through December 2004 were included. After data screening, appropriate analytical approaches were adopted for analysis which included: (1) descriptive statistics—providing a basic description of sample data; (2) one-way ANOVA—comparing the means of difference to fixed fee ratios between clinical departments, MDCs, and DRGs, respectively, and comparing the means of difference to fixed fee ratios across physicians in specific MDCs and/or DRGs; and (3) Scheffe’s multiple comparisons—identifying the units with statistically significant difference. Briefly speaking, the results show that, among all clinical departments, the department of internal medicine would incur the highest financial risk had the DRG reimbursement system been put in action, followed by department of surgery, and department of pediatrics; in contrast, department of orthopedics and department of obstetrics & gynecology would stand in a more favorable stance. In terms of financial risks for different MDCs, the results show that the MDC01 patients (diseases on nerve system) would cause the highest financial risk and, to the contrary, MDC14 patients (pregnancy, birth & nursing periods) would be at the lowest financial risk. In addition, the financial risks that different physicians would bring forth in treating same type of MDC patients would be significantly different in the categories of MDC01, MDC04, MDC05, MDC06 and MDC08. Further, when inpatient services were examined for physicians treating same DRGs cases, the result shows that the financial risks did not reach significant difference. In summary, there exist significant differences in the financial risks for treating patients in different clinical departments. Therefore, it is suggested hereby that appropriate operations programs be developed and implemented in accordance with the characteristics of different clinical departments and needs of patients so as to meet financial risk balance. As for the financial risks on treatment of different MDC patients, since there also exist significant differences, it is proposed hereby that it would be better to identify those major disease categories in the local community and then make best use of hospital specialty and medical resources to effectively reduce the financial risks on treatment of different types of MDC patients. What deserves closer attentions is the fact that physicians would cause significant differences in the financial risks on treatment of same type of MDC patients. Therefore, from the perspective of operations management, it would be necessary to launch certain programs (e.g., clinical guideline, restrictions on consumption of supplies and medicine, etc.) to help physicians to use medical resources in a more financially efficient way.

碩士<br>國立高雄應用科技大學<br>商務經營研究所<br>98<br>In the aim to control the reasonable growth of medical expenses and establish a reasonable reimbursement basis under the existing global budget payment scheme, on January 1, 2010, the National Central Health Insurance Bureau officially launched in phases the 3rd version of DRGs (Diagnosis Related Groups), which superseded “Fee-For-Service” and became the principle for hospitalization medical expenses reimbursement. The research adapted “secondary data” – Utilizing the real hospitalization medical expenses declared to National Health Insurance Bureau by the sampled hospital for the period of Jan. 2009 to Dec. 2009 – applying the fixed amount payment under DRGs, to identify the difference from the actual medical expenses and the ratio of the difference over the fixed amount payment defines as Financial Index used to evaluate the financial impacts of the sample hospital under the new payment principle(DRGs). The research is to explore; under DRGs reimbursement system; whether there is any significant differences in its Financial Index between each respective clinical department, each respective MDC (Major Diagnostic Categories), in addition, between each respective clinical department under the same MDC. Furthermore, to utilize the factors impacting the hospitalization medical expenses to establish the forecast model and eventually provide the sample hospital a strategic reference. The findings of the research indicated that under DRGs reimbursement system, among the six major departments, orthopedic and surgical department’s Financial Index are relatively high with positive increase in terms of financial performance. The other four departments include internal, gynecology, pediatrics and other departments appeared to be “negative” with decreased financial performance. There is significantly different financial influence in between the each respective eight major MDCs, except MDC#11 (kidney and the urethra relevant disease) and the MDC8(skeleton、the muscular system and the connective tissue relevant diseases) present positive figures, all the other six MDCs indicate negative, except MDC5(Circulation Desease), the rest of seven MDCs indicates significant differential in its financial performance due to different department. Regression Analysis indicates “positive” in terms of the relevance between age and MDC3(ENT and oral disease) but negative against to MDC6 (Disease of digestive system), MDC7 (diseases of hepatibilary system or pancreas) and MDC11 (diseases relevant to kidney and urethra). The factor of gender only indicates significant differential in MDC3 and MDC11. All eight MDCs indicate a ‘negative” relevance with “Days of hospitalization’ but a positive relevance with “relative weighting”. In terms of medical resource consumption control, core clinical specialties are relatively superior to non-core clinical specialties. The result of the research concludes that different department and MDC indicates significant differential, the same MDC in different department indicates significant differential. In order to reduce the overall financial risk and boost up the overall financial performance of the sample hospital, it should look into the detailed therapy procedures of those MDC with the relative high Financial Index and create a role model, meanwhile to enforce the cost control on those MDCs/Departments with relatively poor financial performance.

博士<br>國立臺灣大學<br>會計學研究所<br>96<br>Rapidly rising pharmaceutical costs have been a worldwide problem. Under such pressure, governments in many countries have launched various programs in order to curtail the growth of drug expenditure; among them, drug price control is frequently used. Extant research, however, has used macro-level (aggregate) data and can only provide very limited insights into the effect of the drug price control policy on health care providers’ prescription behaviors. Consequently, these works fall short in examining whether the pharmaceutical price control policy can improve the cost-curative effect of pharmaceutical use, and whether the drug price control policy may have different influences on health care providers with different characteristics. This study investigates influences of Taiwan’s drug reimbursement rate reduction policy in its National Health Insurance system on the price level and the cost-curative effect of pharmaceutical use, using hypertension patients’ usage of hypotensive agents as the example for such analysis. Specifically, we take advantage of the rich content of data in the National Health Insurance Research Database to construct a micro-level database that enables us to examine the following additional two issues: (1) whether the pharmaceutical price control policy has helped improve the cost-curative effect of usage of hypotensive agents, and (2) whether this policy has different effects on health care providers with different characteristics. We used Taiwanese hypertension patients aged 40 or over as our study population. This population accounts for almost the entire population of hypertension patients who take prescription drugs. We selected the two most used narrow classes of hypotensive agents based on the first four digits of the coding system of Anatomical Therapeutic Classification (ATC). They are peripherally acting antiadrenergic agents (ATC code=C02C) and plain angiotensin II antagonists (ATC code=C09C).To provide insights into whether the reimbursement rate reduction policy has had different effects for hospitals with different characteristics, we apply the hierarchical linear modeling (HLM) technique. Findings from this study indicate that the price control initiatives between 2000 and 2003 were not helpful for improving the cost-curative effect of using the C02C and the C09C drugs, since the daily expense was not reduced for these two drug classes because of the initiatives. As the magnitude of price reduction level was small for each of the two drug classes, such findings reflect the uselessness of the small price reduction. While the drug price control policy had insignificant effects on the daily expense for the C02C drugs and the C09C drugs, variations in the influence existed among health care providers with different characteristics. Physicians in public hospitals appeared to prescribe cheaper C09C drugs after the 2000 price reduction. In contrast, physicians in medical centers tended to prescribe more expensive drugs in the two classes after a reimbursement rate reduction action. The percentage of the specialist group comprising cardiologists, nephrologists, and internal medicine physicians in a hospital was associated with a tendency to prescribe more expensive C09C drugs after the 2001 and the 2003 reductions. The different changes in the daily expense after the drug price reductions for hospitals suggest that hospitals with different characteristics might have different patterns of switching drug types in their prescriptions or some patients might switch hospitals after an action of reimbursement rate reduction. Such results suggest a need for the government to better monitor health providers’ behavior of switching prescription drugs and patients’ behavior of switching hospitals so as to have a better understanding with respect to how drug price control actions could affect pharmaceutical expenditures and health care quality.

Relatório de Estágio do Mestrado Integrado em Ciências Farmacêuticas apresentado à Faculdade de Farmácia<br>A autorização de introdução no mercado de um novo medicamento constitui umavitória para a indústria farmacêutica porém, o acesso ao mercado e a negociação de preços ede reembolsos pode constituir-se uma tarefa difícil, uma vez que é necessário demonstrarvalor terapêutico acrescentado a um preço adequado, num momento em que a robustez daevidência clínica e dos estudos económicos poderá não ser suficiente.Em Portugal, o Sistema Nacional de Avaliação de Tecnologias de Saúde, em permanenteevolução e harmonizado com os demais sistemas europeus de avaliação, auxilia nas decisõessobre o preço, a comparticipação, a aquisição ou a instalação das tecnologias de saúde no SNS,baseadas em avaliações técnicas, terapêuticas e económicas, as quais seguem as guidelines emvigor, garantindo a transparência de todo este processo, a correta alocação dos recursos emelhorias na prática clínica, benéficas quer para o cidadão, quer para a sociedade.Foram caracterizados os medicamentos aprovados em 2016 por procedimentocentralizado e avaliados pelo INFARMED, I.P. até março de 2019 inclusive. Também seencontram caracterizados os respetivos processos de avaliação e identificados alguns dosfatores que tornam a avaliação das tecnologias de saúde morosa comparativamente à médiaeuropeia, não só com impacte nos doentes, que têm o acesso tardio e desigual aomedicamento, mas também na indústria farmacêutica, que vê reduzidos os seus períodos deexclusividade de mercado e respetivos ganhos, dada a posterior comercialização demedicamentos genéricos, biossimilares ou demais alternativas terapêuticas.<br>The granting of a marketing authorisation to a new drug is a victory for thepharmaceutical industry. Despite this, the market access which includes negotiation of pricesand reimbursements can be a difficult task because it is necessary to demonstrate addedtherapeutic value at an appropriate price, at a time when the robustness of clinical evidenceand economic studies may not be sufficient.In Portugal, the National Health Technology Assessment System, in constant evolutionand harmonized with other European evaluation systems, helps in decisions on the price,reimbursement, acquisition or installation of health technologies in the National HealthSystem, based on technical, therapeutic and economic evaluations, in accordance with specificguidelines, guaranteeing the transparency of the process, the correct allocation of resourcesand improvements in clinical practice, beneficial to the citizen and society.The drugs approved in 2016 by centralized procedure were characterized andevaluated until March 2019 inclusive by INFARMED, I.P.. Moreover, the respective healthtechnologies assessment processes were characterized and some factors that make it moretime-consuming than European average were identified. This delay not only has impact on thepatients, who have delayed and unequal access to the medicine, but also in the pharmaceuticalindustry, which has a reduced period of market exclusivity and a lower financial return due togenerics, biosimilars or other therapeutic alternatives.

L’assurance médicaments est un des facteurs qui peuvent influencer l’adhésion aux médicaments. Les objectifs de ce mémoire étaient d’évaluer l’impact du type d’assurance médicaments (publique versus privée) sur l’adhésion et le coût des antihypertenseurs et d’évaluer l’impact des procédures de remboursement et de la contribution du patient sur l’adhésion aux médicaments prescrits pour traiter une maladie chronique. Afin de répondre à ces objectifs, deux cohortes rétrospectives ont été construites à partir des bases de données de la RAMQ et reMed : une cohorte appariée d’utilisateurs d’antihypertenseurs couverts par une assurance médicaments privée ou publique et une cohorte de patients couverts par une assurance médicaments privée ayant rempli au moins une ordonnance pour un médicament traitant une maladie chronique. Les résultats montrent que le niveau d’adhésion aux antihypertenseurs était similaire entre les deux types d’assurance médicaments et que le coût des antihypertenseurs était 28,9 % plus élevé au privé. De plus, il a été observé que les procédures de remboursement n’affectaient pas l’adhésion, alors que le niveau de contribution des patients l’affectait. Les patients qui déboursaient un plus grand montant à l’achat de leurs médicaments étaient moins adhérents (différence : -19,0 %, Intervalle de confiance [IC] à 95 % : -24,0 à -13,0), alors que les patients qui n’avaient rien à débourser étaient moins adhérents (différence : -9,0 %, IC à 95 % : -15,0 à -2,0), que ceux qui devaient débourser une petite somme. Les résultats présentés dans ce mémoire montrent que l’assurance médicaments influence l’adhésion par l’entremise des caractéristiques des plans d’assurance.<br>Drug insurance is one of many factors that can influence medication adherence. The objectives of this thesis were to evaluate the impact of the type of drug insurance (private versus public) on adherence to antihypertensive medications and the cost of medications, and to evaluate the impact of drug reimbursement procedures and out-of pocket expenses on adherence to medications prescribed for chronic diseases. To meet these objectives, two retrospective cohorts were constructed from the RAMQ and reMed databases: a matched cohort of antihypertensive users covered by private or public drug insurance and a cohort of patients covered by private drug insurance who filled at least one prescription for a medication prescribed for a chronic disease. The results have shown that the level of adherence to antihypertensive medications was similar between the two types of drug insurance and that the cost of antihypertensive medications was 28,9% higher for those privately insured. It was also observed that drug reimbursement procedures didn’t affect medication adherence, while the level of out-of-pocket expenses affected it. Patients with the highest out-of-pocket expenses were less adherent (difference: –19.0%; 95% confidence interval [CI]: –24.0 to –13.0), while patients with no out-of-pocket expenses were less adherent (difference: -9.0%; 95% CI: –15.0 to –2.0) than those with low out-of-pocket expenses. The results presented in this thesis have shown that drug insurance affects medication adherence through the characteristics of drug insurance plans.