Ethnicity and the Impact of Higher Medication Copayments among Patients with Schizophrenia

Authors: John E. Zeber, PhD; Laurel A. Copeland, PhD; Alexander L. Miller, MD; Amy M. Kilbourne, PhD; Dawn Velligan, PhD; Eric M. Mortensen, MD

Background:
In 2002, medication copayments in the Veterans Healthcare system increased from $2 to $7. Patients with schizophrenia constitute a multiply disadvantaged population; 40% are antipsychotic non-adherent, substantially increasing psychiatric admission risks. Minority patients might be particularly sensitive to copayments and experience significant ramifications from higher out-of-pocket pharmacy costs. Diverse cultural expressions of health beliefs and treatment priorities add layers of complexity to potential ethnic disparities stemming from mental health policy changes.

Methods:
Veterans with schizophrenia were followed 33 months before and after the copayment increase, with longitudinal mixed effects models analyzing responses to higher medication costs. Adjusted means compared differences in prescription fills and psychiatric inpatient days among four ethnic groups: White (N=36,452), African-American (N=17,602), Hispanic (N=5,225), and Other (N=10,707). Covariates included demographics, substance abuse, functional status, and other comorbidities.

Results:
Hispanic veterans were more likely to be unmarried and have multiple illnesses than other patients. Prior to 2002, minority patients filled one-third fewer prescriptions than white veterans. Ethnic differences were also evident in pharmacy patterns and inpatient days following the policy change. White veterans reduced psychotropic fills 16% while decreasing hospital days by 10%. Although minority prescriptions also declined 19 – 22%, inpatient utilization significantly increased. In particular, Hispanic patients were most strongly affected by higher copayments, averaging 10% additional psychiatric hospital days.

Conclusions:
Although all groups considerably restricted pharmacy use due to higher copayments, especially psychotropic fills, ethnic minorities appeared particularly sensitive to increased drug costs. Similarly, while white veterans reduced psychotropic use with minimal consequences, minorities experienced substantially elevated admission risks associated with lower cost-related adherence. Hispanics were acutely vulnerable to adjusting fill patterns with subsequent clinical ramifications. Benefit changes for chronically ill patients should be implemented cautiously and carefully evaluated, with sensitive attention to unique patient groups to ensure equity while minimizing economic and health disparities.