Amal Trivedi, MD, MPH Providence VA Medical Center Brown University School of Public Health

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

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

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

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

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

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

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

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

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

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

11. Uptake of PBS Incentive in Sentinel Sites and Rest of Australia

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

13. Uptake of PBS Incentive Across Sentinel Sites

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

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

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

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

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

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

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

21. Principal Diagnoses of Hospitalizations

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

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

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