 |
 |
|
Home |
Current Issue |
Past Issues |
In the Clinic |
ACP Journal Club |
CME |
Collections |
Audio/Video |
Mobile |
Subscribe |
Tools |
Help |
ACP Online
|
7 June 2005 | Volume 142 Issue 11 | Pages 891-897
Background: Generic substitution is one mechanism of curtailing prescription drug expenditures. Limited information is available about the potential savings associated with generic substitution.
Objective: To estimate the potential savings associated with broad substitution of generic drugs.
Design: Cross-sectional, nationally representative survey of noninstitutionalized adults.
Setting: United States.
Participants: Adults included in the Medical Expenditure Panel Survey Household Component, 1997–2000.
Measurements: Use of a multisource drug (that is, a drug available in a brand-name and
Results: Fifty-six percent of all outpatient drugs were multisource products, accounting for 41% of total outpatient drug expenditures. Of these multisource drugs, 61% were dispensed as a generic. If a generic had been substituted for all corresponding brand-name outpatient drugs in 2000, the median annual savings in drug expenditures per person would have been $45.89 (interquartile range, $10.35 to 158.06) for adults younger than 65 years of age and $78.05 (interquartile range, $19.94 to $241.72) for adults at least 65 years of age. In these age groups, the national savings would have been $5.9 billion (95% CI, $5.5 billion to $6.2 billion) and $2.9 billion (CI, $2.6 billion to $3.1 billion), respectively, representing approximately 11% of drug expenditures.
Limitations: Specific information about an individual's formulary was not available, so the authors could not estimate how much of the potential savings would benefit an individual or his or her health plan.
Conclusion: Although broad substitution of generic drugs would affect only a modest percentage of drug expenditures, it could result in substantial absolute savings.
Contribution
Implication
–The Editors
Prescription drug spending is increasing at a rate of over 10% per year and currently represents 11% of all health care expenditures (1). In 2001, expenditures for prescription drugs in the United States were $141 billion (1). The passage of a Medicare prescription drug benefit has resulted in much debate about the cost of this coverage. The program is designed to offer $410 billion in new drug benefits over a 10-year period (2). Containment of drug spending will be central to the stability of this benefit as well as health care expenditures in general.
Generic drugs are typically less expensive than brand-name drugs, and prices for generics have historically increased less than those for brand-name drugs (3). The U.S. Food and Drug Administration examines generic formulations and approves them as bioequivalent to brand-name drugs in safety, strength, and quality (4). Although the bioequivalence of some drugs is controversial (5-7), generic drugs are widely believed to provide the same therapeutic effects as their brand-name alternatives (4).
Use of a generic formulation instead of a brand name for multisource drugs (that is, those with
The objectives of this study were to estimate the use of multisource drugs, specifically generic formulations, among a nationally representative sample of adults. We also estimated the potential savings associated with broad substitution of generic drugs for all multisource products. Because of their implications for the Medicare drug benefit, our findings are stratified by age.
This analysis is based on data from the 1997-2000 Medical Expenditure Panel Survey Household Component (MEPS-HC), which involved a nationally representative sample of the civilian, noninstitutionalized U.S. population and was conducted by the Agency for Healthcare Research and Quality (17). The MEPS-HC sample is drawn from respondents to the previous year's National Health Interview Survey (NHIS). The NHIS uses a stratified, multistage probability cluster sampling design to obtain a representative sample of the U.S. population and oversamples persons of African-American and Hispanic ethnicity (18). The MEPS-HC data include sampling weights that reflect the sampling frame and adjustments for household nonresponse. The MEPS-HC provides data on demographic characteristics, health status, insurance coverage, and the utilization of health care services for all individuals in sampled households. Household respondents provided information on the names of all outpatient medications used by each household member and the names and locations of the pharmacies where each medication was obtained (19). They were also asked for permission to request records from these pharmacies. Pharmacy providers were asked to provide the data necessary to assign a National Drug Code, which is specific for manufacturer, ingredients, strength, package size, quantity dispensed, total charge, and sources of payment. The linkage rate between information provided by respondents and data obtained from pharmacies was 67% in 1997, 79% in 1998, 79% in 1999, and 77% in 2000. The Agency for Healthcare Research and Quality performed detailed matching, imputation, consistency checks, sensitivity checks, and reconciliation algorithms (19).
Data for each drug from the First DataBank National Drug Data File were merged with the MEPS data by using the National Drug Code. The National Drug Data File indicates whether a drug is available only as a brand name or as a multisource product; generic status is assigned annually. The National Drug Data File also includes a categorization of the therapeutic class and the average wholesale price for each product. The average wholesale price is the manufacturer's suggested list price for a wholesaler to charge a pharmacy and is typically higher than a pharmacy's actual acquisition cost, particularly for brand-name drugs (3).
Study Sample
Adults who were older than 18 years of age and used at least 1 outpatient multisource product were included in this analysis. Brand-name drugs were included in the analysis only if a generic alternative was available in an identical strength and form. A median of 4 prescriptions per person (range, 1 to 60 prescriptions per person) was included in this sample.
Calculation of Prices and Potential Savings
Because retail prices for medications vary widely and are not uniformly available, we used data from MEPS about the total expenditures for each drug (that is, the amount spent by an individual out-of-pocket plus the amount paid by any insurance coverage). We then calculated the mean total cost per unit (that is, per tablet, tube, vial, or dropper bottle, as appropriate) for each of the 7056 products used by individuals in our sample (that is, we calculated the average per unit cost for all occurrences of each product). The availability of the actual drug expenditures for each product is an improvement over previous estimates of drug costs, which used a standard discount of the average wholesale price because actual expenditures were not available (for example, estimating that all generic drugs cost 75% of the average wholesale price) (20, 21). We then estimated the annual savings that would result if each person in the sample switched from a brand-name drug to a corresponding generic formulation, using the following equation:
Annual savings =
Using data from 2000, we calculated overall savings from a population perspective (for example, total saved for all people
Role of the Funding Sources
This work was supported by the Agency for Healthcare Research and Quality (P01 HS10771 and P01 HS 10856). The National Cancer Institute provided partial support (R01 CA 10184). The funding sources had no role in the design, conduct, or reporting of the study.
Fifty-six percent of all prescription medications (345 781 observations that were weighted to represent 3 686 700 000 prescriptions from 1997 to 2000) were multisource drugs, accounting for 41% of total prescription drug expenditures. Of these drugs, 61% were dispensed as a generic. Generic use increased over the course of the study, from 58% in 1997 to 64% in 2000. In 2000, total medication expenditures for adults in MEPS were $53 billion for those younger than age 65 years and $27 billion for those at least 65 years of age.
Among adults who were dispensed a multisource drug in MEPS, approximately 75% were younger than age 65 years and approximately 25% were at least 65 years of age (Table 1). Most individuals in both age groups were women and described their race or ethnicity as white. Among individuals younger than 65 years of age, approximately half did not receive education beyond high school; the median household income was $54 761. While most of these working-age adults had employer-sponsored insurance, 14.4% were uninsured and 7.6% were covered by Medicaid or another public program. Most did not report any comorbid conditions. The median annual number of prescriptions dispensed was 3. ARTICLE
Potential Savings from Substituting Generic Drugs for Brand-Name Drugs: Medical Expenditure Panel Survey, 1997–2000
1 generic formulation) or a generic drug and the potential cost savings associated with broad generic substitution for all multisource products.
Editors' Notes
Top
Editors' Notes
Methods
Results
Discussion
Author & Article Info
References
Context
1 generic available) could be one mechanism for limiting drug expenditures. Since the 1980s, almost every state has enacted laws to allow and in some cases mandate generic substitution (8). Patients, physicians, and pharmacists may also influence whether a generic is dispensed for a multisource product (9-15). A study of Medicaid prescription drug spending in 2000 found that $229 million, approximately 1% of the total amount reimbursed for prescription drugs by Medicaid, could have been saved by wider use of generic drugs (16). Despite the importance of this issue, we know of no estimates of the potential savings associated with greater generic substitution in populations other than Medicaid beneficiaries.
Methods
Top
Editors' Notes
Methods
Results
Discussion
Author & Article Info
References
Data
(total units of brand-name product dispensed per year) x (average per unit expenditure for brand-name product – average per unit expenditure for identical generic product). 65 years of age) and as median annual savings per person (for example, out-of-pocket savings plus savings to any insurance plan per person). Calculations were done with SAS, version 8 (SAS Institute, Inc., Cary, North Carolina); the sampling weights described earlier were used to account for differences in the probability of sample selection as a result of the clustered design, planned oversampling, and nonresponse. The weighted results therefore represent estimates for the noninstitutionalized U.S. population.
Results
Top
Editors' Notes
Methods
Results
Discussion
Author & Article Info
References
Persons Using a Multisource Drug
|
Among individuals at least 65 years of age, 68.9% did not receive education beyond high school; the median household income was $26 274. Approximately 33% had only Medicare coverage, 57.1% had additional private coverage, and 9.5% had additional public coverage, including Medicaid. Almost half reported at least 1 comorbid condition. The median annual number of prescriptions dispensed was 8.
Characteristics of Multisource Prescriptions
For individuals younger than 65 years of age, the most common therapeutic classes of multisource drugs dispensed were psychiatric, analgesic, and cardiac (Table 2). Among individuals at least 65 years of age, cardiac drugs were the most common drugs dispensed, followed by diuretics and psychiatric drugs. Overall, 60.7% of multisource prescriptions were dispensed as generics. Thyroid medications were most likely to be dispensed as generics, and contraceptives were least likely. Broad generic substitution of antihistamines and cardiac, gastrointestinal, and hypoglycemic agents were each associated with a potential annual savings of more than $1 billion.
|
Potential Median Annual Savings Associated with Generic Substitution
For adults younger than age 65 years, the median annual per person savings associated with broad generic substitution was $45.89 (interquartile range, $10.35 to 158.06) (Table 3). This savings would be shared between an individual and his or her health plan. Median per person savings increased with age and number of chronic conditions, and men saved more than women. Median per person savings were largest for low-income individuals and varied by insurance status.
|
For adults at least 65 years of age, the median annual per person savings associated with broad generic substitution was $78.05 (interquartile range, $19.94 to $241.72). Median per person savings increased with the number of chronic conditions and varied by insurance status.
National Savings Associated with Generic Substitution
The estimated national savings associated with widespread generic substitution in 2000 was $5.9 billion (95% CI, $5.5 billion to $6.2 billion) per year for adults younger than 65 years of age (11.1% of all drug expenditures) and $2.9 billion (CI, $2.6 billion to $3.1 billion) per year among those at least 65 years of age (10.7% of drug expenditures). From a national perspective, the potential annual savings associated with generic substitution among adults younger than 65 years of age was $4.1 billion for those with employer-sponsored insurance and $388 million for those with Medicaid or public coverage. For adults at least 65 years of age who were dually eligible for Medicare and Medicaid, the potential savings was $1.7 billion per year.
Discussion
|
|---|
|
TopEditors' NotesMethodsResultsDiscussionAuthor & Article InfoReferences |
|---|
Although broad generic substitution would only modestly reduce national drug expenditures, the absolute savings, particularly at a time when employers and public programs are struggling with drug expenditures, are significant. Broad dispensing of generic products would achieve savings without compromising safety. Generic drugs are believed to provide therapeutic effects similar to those of their brand-name alternatives (4). The standards and regulations for manufacturing generic products are the same as for brand-name drugs (22). Recent efforts to remove barriers to generic drug approval suggest that policymakers see an opportunity to control expenditures through greater use of generic drugs (4, 23). However, some have argued that greater generic substitution could limit drug development by pharmaceutical companies because of decreased revenue (24).
Using aggregate data for Medicaid drug payments from 48 states in 2000, Fischer and Avorn (16) estimated that approximately $229 million (approximately 1% of total drug expenditures) could have been saved through wider generic substitution. These data did not include information on the 56% of Medicaid beneficiaries who were covered by a managed care plan in 2000 (25). Our estimate of the savings for persons covered solely by Medicaid was higher, perhaps because our sample included individuals covered by a managed care plan. Differences in the estimates may also be related to differences in the calculations of the cost of prescription medications. Fischer and Avorn's estimate was based on the lowest generic price for each product paid by Medicaid in a particular state, whereas ours was based on the average total cost reported by individuals in MEPS nationwide. Our analysis also estimated savings for individuals with other types of health coverage. Medicaid beneficiaries are likely to use a different array of brand-name and multisource drugs than adults with other forms of health coverage.
Choosing a brand-name drug when a generic is available may be influenced by a variety of factors. State laws regulate generic substitution. While most states permit pharmacists to substitute a generic unless directed by the physician or patient, a minority of states mandate that a pharmacist substitute a generic unless overridden by a physician's order (8). Health plan policies may facilitate the use of generic drugs. However, although tiered formularies may encourage the use of generics, they may also lead to greater out-of-pocket expenditures and even to the discontinuation of long-term medications (26). Reference pricing may encourage greater use of generic drugs by offering reimbursement for the lowest-priced therapeutically equivalent drug (27). Some patients may believe that a brand-name formulation is superior (9, 10), perhaps because direct-to-consumer advertising influences patient beliefs about medications (28). Previous research has shown that physicians and pharmacists play an important role in the decision to choose a brand-name or generic formulation of a drug (11-15).
Our analysis does not include the substitution of drugs within a class (that is, therapeutic substitution). We included only brand-name drugs with an identical generic. Therapeutic substitution of angiotensin-converting enzyme inhibitors has been shown to reduce expenditures without adverse clinical outcomes (29). Future research should more broadly examine the effect of therapeutic substitution on clinical outcomes and expenditures.
Our study has several additional limitations. Because retail drug pricing in the United States varies widely and is proprietary, there are no nationwide data to calculate actual costs or savings. For this reason, we used costs reported in MEPS. We do not have information about formularies or copayments required by health plans for specific products, both of which may influence the utilization of specific medications (26, 30). We also cannot calculate how much of the potential savings would benefit individuals or their health plans. Regardless of the distribution, however, we believe that the savings are important from a societal perspective because they result from curtailing unnecessary expenditures for drugs that have an identical generic available.
Our study examined the potential savings associated with generic substitution through 2000. In subsequent years, several "blockbuster" drugs have lost patent protection (31, 32). Because detailed pharmacy data were available for 67% to 79% of the MEPS sample (depending on the year), our findings underestimate total drug expenditures in the United States. We do not know whether MEPS respondents who used a multisource drug were more or less likely to be matched with a pharmacy claim. Finally, we did not examine the potential savings associated with greater generic substitution among children.
These data provide per person and national estimates of the potential savings associated with broad generic substitution of outpatient prescription drugs for adults. Interventions to stimulate competition in the generic market, to reduce the approval times for generic drugs by the U.S. Food and Drug Administration, and to limit opportunities to extend the patent life of brand-name drugs could increase the potential savings (33, 34). Greater use of generic medications could result in important health care savings in the United States while maintaining quality of care.
Author and Article Information
|
|---|
|
TopEditors' NotesMethodsResultsDiscussionAuthor & Article InfoReferences |
|---|
Acknowledgments: The authors thank Jaylyn Olivo for editorial assistance and Dr. Michael Fischer for comments on an earlier version of the manuscript.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Jennifer S. Haas, MD, MSPH, Brigham and Women's Hospital, Division of General Medicine and Primary Care, 1620 Tremont Street, Boston, MA 02120; e-mail, jhaas{at}partners.org.
Author Contributions: Conception and design: J.S. Haas, K.A. Phillips.
Analysis and interpretation of the data: J.S. Haas, K.A. Phillips, E.P. Gerstenberger, A.C. Seger.
Drafting of the article: J.S. Haas.
Critical revision of the article for important intellectual content: K.A. Phillips, A.C. Seger.
Final approval of the article: J.S. Haas, K.A. Phillips, E.P. Gerstenberger, A.C. Seger.
Provision of study materials or patients: J.S. Haas.
Statistical expertise: J.S. Haas, E.P. Gerstenberger.
Obtaining of funding: J.S. Haas, K.A. Phillips.
Administrative, technical, or logistic support: J.S. Haas.
Collection and assembly of data: J.S. Haas, K.A. Phillips.
Current Author Addresses: Drs. Haas and Seger and Mr. Gerstenberger: Brigham and Women's Hospital, Division of General Medicine and Primary Care, 1620 Tremont Street, Boston, MA 02120.
Dr. Phillips: Box 0613, University of California, San Francisco, San Francisco, CA 94143.
References
|
|---|
|
TopEditors' NotesMethodsResultsDiscussionAuthor & Article InfoReferences |
|---|
1. Henry J. Kaiser Family Foundation. Prescription Drug Trends. Menlo Park, CA: Henry J. Kaiser Family Foundation; May 2003.
2. Moon M. How Beneficiaries Fare under the New Medicare Drug Bill. The Commonwealth Fund. June 2004. Available at http://www.cmwf.org/usr_doc/moon_medicarerxdrug_ib_730.pdf.
3. Prescription Drug Trends—A Chartbook Update. Menlo Park, CA: Henry J. Kaiser Family Foundation; 2001.
4. Nightingale SL. From the Food and Drug Administration. JAMA. 1998;279:645 [PMID: 9496968].
5. Dong BJ, Hauck WW, Gambertoglio JG, Gee L, White JR, Bubp JL, et al. Bioequivalence of generic and brand-name levothyroxine products in the treatment of hypothyroidism. JAMA. 1997;277:1205-13. [PMID: 9103344].[Abstract]
6. Rennie D. Thyroid storm [Editorial]. JAMA. 1997;277:1238-43. [PMID: 9103350].[Medline]
7. DeCara JM, Croze S, Falk RH. Generic warfarin: a cost-effective alternative to brand-name drug or a clinical wild card? [Editorial] Chest. 1998;113:261-3. [PMID: 9498932].
8. National Institute for Health Care Management Foundation. A Primer: Generic Drugs, Patents and the Pharmaceutical Marketplace. June 2002. Available at http://www.nihcm.org/GenericsPrimer.pdf.
9. Gaither CA, Kirking DM, Ascione FJ, Welage LS. Consumers' views on generic medications. J Am Pharm Assoc. 2001;41:729-36.
10. Brennan TA, Lee TH. Allergic to generics. Ann Intern Med. 2004;141:126-30. [PMID: 15262668].
11. Hellerstein JK. The importance of the physician in the generic versus trade-name prescription decision. Rand J Econ. 1998;29:108-36. [PMID: 10182437].[Medline]
12. Banahan BF 3rd, Kolassa EM. A physician survey on generic drugs and substitution of critical dose medications. Arch Intern Med. 1997;157:2080-8. [PMID: 9382664].[Abstract]
13. Mott DA, Cline RR. Exploring generic drug use behavior: the role of prescribers and pharmacists in the opportunity for generic drug use and generic substitution. Med Care. 2002;40:662-74. [PMID: 12187180].[Medline]
14. Suh DC. Trends of generic substitution in community pharmacies. Pharm World Sci. 1999;21:260-5. [PMID: 10658234].[Medline]
15. Ganther JM, Kreling DH. Consumer perceptions of risk and required cost savings for generic prescription drugs. J Am Pharm Assoc (Wash). 2000;40:378-83. [PMID: 10853539].
16. Fischer MA, Avorn J. Economic consequences of underuse of generic drugs: evidence from Medicaid and implications for prescription drug benefit plans. Health Serv Res. 2003;38:1051-63. [PMID: 12968816].[Medline]
17. Cohen JW, Monheit AC, Beauregard KM, Cohen SB, Lefkowitz DC, Potter DE, et al. The Medical Expenditure Panel Survey: a national health information resource. Inquiry. 1996;33:373-89. [PMID: 9031653].
18. Cohen SB, DiGaetano R, Goskel H. Estimation Procedures in the 1996 Medical Expenditures Panel Survey Household Component. Rockville, MD: Agency for Health Care Policy and Research; 1999. MEPS Methodology Report No. 5. AHCPR Pub. No. 99-0027. Available at http://www.meps.ahrq.gov/papers/mr5_99-0027/mr5.htm.
19. Moeller JF, Stagnitti MN, Horan E, Ward P, Kieffer N, Hock E. Outpatient Prescription Drugs: Data Collection and Editing in the 1996 Medical Expenditure Panel Survey (HC-010A). Rockville, MD: Agency for Healthcare Research and Quality; 2001. MEPS Methodology Report No. 12. AHRQ Pub. No. 01-0002. Available at http://www.meps.ahrq.gov/PAPERS/mr12_01-0002/mr12.htm.
20. Cubanski J, Frank RG, Epstein AM. Savings from drug discount cards: relief for Medicare beneficiaries? Health Aff (Millwood). 2004;W4:198-209. [PMID: 15451980].
21. Anderson GF, Shea DG, Hussey PS, Keyhani S, Zephrin L. MarketWatch: Doughnut holes and price controls. Health Aff (Millwood). 2004;W4:396-404. [PMID: 15451953].
22. Murphy JE. Generic substitution and optimal patient care [Editorial]. Arch Intern Med. 1999;159:429-33. [PMID: 10074950].
23. Harris G. Bush to back measures on generic drugs. New York Times. 12 June 2003:1.
24. Cruickshank JM. The cases for and against prescribing generic drugs: don't take innovative research based pharmaceutical companies for granted. BMJ. 1988;297:1597-8. [PMID: 3147090].
25. The Henry J. Kaiser Family Foundation, Kaiser Commission on Medicaid and the Uninsured. Medicaid and Managed Care. December 2001. Available at http://www.kff.org/medicaid/206803-index.cfm.
26. Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, Frank RG. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med. 2003;349:2224-32. [PMID: 14657430].
27. Schneeweiss S, Dormuth C, Grootendorst P, Soumerai SB, Maclure M. Net health plan savings from reference pricing for angiotensin-converting enzyme inhibitors in elderly British Columbia residents. Med Care. 2004;42:653-60. [PMID: 15213490].[Medline]
28. Robinson AR, Hohmann KB, Rifkin JI, Topp D, Gilroy CM, Pickard JA, et al. Direct-to-consumer pharmaceutical advertising: physician and public opinion and potential effects on the physician-patient relationship. Arch Intern Med. 2004;164:427-32. [PMID: 14980994].
29. Schneeweiss S, Walker AM, Glynn RJ, Maclure M, Dormuth C, Soumerai SB. Outcomes of reference pricing for angiotensin-converting-enzyme inhibitors. N Engl J Med. 2002;346:822-9. [PMID: 11893794].
30. Goldman DP, Joyce GF, Escarce JJ, Pace JE, Solomon MD, Laouri M, et al. Pharmacy benefits and the use of drugs by the chronically ill. JAMA. 2004;291:2344-50. [PMID: 15150206].
31. Drug and formulary trends. Formulary. 2002;38:499.
32. Medco Health Solutions, Inc. Anticipated First-Time Generics, 2004-2006. Available at http://www.medco.com/art/corporate/firsttime_generics_2004_2006.pdf.
33. Bae JP. Drug patent expirations and the speed of generic entry. Health Serv Res. 1997;32:87-101. [PMID: 9108806].[Medline]
34. U.S. Food and Drug Administration. New FDA Initiative on "Improving Access to Generic Drugs." June 11, 2003. Available at http://www.fda.gov/oc/initiatives/generics/whitepaper.html.
Related articles in Annals:
This article has been cited by other articles:
|
|
 |
|
  J. M. Hoffman, N. D. Shah, L. C. Vermeulen, F. Doloresco, P. Grim, R. J. Hunkler, K. M. Hontz, and G. T. Schumock Projecting future drug expenditures--2008 Am. J. Health Syst. Pharm., February 1, 2008; 65(3): 234 - 253. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C.-W. Tseng, C. M. Mangione, R. H. Brook, E. Keeler, and R. A. Dudley Identifying Widely Covered Drugs and Drug Coverage Variation Among Medicare Part D Formularies JAMA, June 20, 2007; 297(23): 2596 - 2602. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. S. Kesselheim, M. A. Fischer, and J. Avorn Extensions Of Intellectual Property Rights And Delayed Adoption Of Generic Drugs: Effects On Medicaid Spending Health Aff., November 1, 2006; 25(6): 1637 - 1647. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Paterson, M. Mamdani, D. N. Juurlink, G. Naglie, A. Laupacis, and T. A. Stukel Clinical consequences of generic warfarin substitution: an ecological study. JAMA, October 25, 2006; 296(16): 1969 - 1972. [Full Text] [PDF]
|
|
|
|
 |
|
 G. S. Liptak, L. P. Shone, P. Auinger, A. W. Dick, S. A. Ryan, and P. G. Szilagyi Short-term Persistence of High Health Care Costs in a Nationally Representative Sample of Children Pediatrics, October 1, 2006; 118(4): e1001 - e1009. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 U. D. Patel and M. M. Davis Falling into the Doughnut Hole: Drug Spending among Beneficiaries with End-Stage Renal Disease under Medicare Part D Plans J. Am. Soc. Nephrol., September 1, 2006; 17(9): 2546 - 2553. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. M. Hoffman, N. D. Shah, L. C. Vermeulen, G. T. Schumock, P. Grim, R. J. Hunkler, and K. M. Hontz Projecting future drug expenditures--2006 Am. J. Health Syst. Pharm., January 15, 2006; 63(2): 123 - 138. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M.-L. Laroche and L. Merle Generic Drug Savings Ann Intern Med, December 6, 2005; 143(11): 844 - 845. [Full Text] [PDF]
|
|
|
|
 |
|
 A. Tonks What's new in the other general journals BMJ, June 25, 2005; 330(7506): 1469 - 1470. [Full Text] [PDF]
|
|
Read all Rapid Responses
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Article
