Impacts of Policy Changes and the Role of Institutional Structures in Healthcare: Exploring Outcomes Related to the Pharmacological Care of Type 2 Diabetes
Abstract
Health and social protection systems offer care and security in times of need. A wellfunctioning system can also help mediate the consequences of unequally distributed determinants of ill-health. However, the structures of a system may also invite nonclinical factors such as the socioeconomic status of a patient influence the receipt of care. The capability of the system to provide for those in need is thus a complex whole, with policy interplays and interconnected institutional structures further hampering the possibilities for evaluating the role of distinct features in provision of care and security.
Using prescription medicines as an example of healthcare service, the four articles in this dissertation examine policies and institutional structures affecting healthcare. The articles utilise study designs arising from policy reforms and structures of healthcare system that affect patients with type 2 diabetes, a chronic disease that requires long-term pharmacological treatment. The first and second articles examine the effects of a reform within the affected system by studying the impacts of increased medicine co-payment on medicine use on all affected patients and on patients from different socioeconomic backgrounds. The third article concentrates on institutional interplays and studies the impact of increased copayment on the receipt of social assistance, a last-resort financial aid. The fourth article focuses further on the role of institutional structures and analyses the medicine prescribing patterns for patients using services in public, private and occupational healthcare.
The first three articles use nationwide Finnish register data from 2010−2019 and exploit a quasi-experimental setting caused by the introduction of a reform that increased the co-payment for non-insulin type 2 diabetes medicines. Populationlevel impacts on medicine use are investigated with interrupted time-series analysis and segmented regression. Analysis of socioeconomic differences in take-up of insulin after the reform utilises proportional hazard method. Insulin is often a less optimal but from the patients’ perspective a cheaper treatment alternative. The impact of co-payment increase on social assistance receipt is studied using difference-in-differences analysis. The fourth article uses descriptive methods and logistic regressions with comprehensive regional level register data from 2013−2018 to evaluate the prescribing patterns reflecting clinical guidelines of care in patients receiving prescriptions for novel non-insulin type 2 diabetes medicines in different healthcare sectors.
The results showed that after the reform increasing the co-payment for noninsulin type 2 diabetes medicines, the total consumption of these medicines declined. However, the consumption of insulins did not increase. There were also no differences in the development of insulin initiation patterns between patients with different socioeconomic position after the reform. The effects of the reimbursement system reform seemed, however, to spread to the social assistance system, as the probability of social assistance receipt rose in patients using type 2 diabetes medicines. This also suggests an impact on the affordability of the affected medicines. The likelihood of insulin initiation in patients with type 2 diabetes was found to be declining during the study period, reflecting novel type 2 diabetes medicines entering the reimbursement system. The characteristics of patients initiating novel medicines in different healthcare sectors aligned with the known socioeconomic differentiation of Finnish primary care, but the prior prescribing patterns in all sectors reflected the clinical guidelines of type 2 diabetes care. The higher likelihood of prior insulin use in patients initiating novel medicines in public sector compared to patients initiating them in occupational care implied the possibility of initiation at a later stage or unaccounted differences in patient characteristics.
Overall, the study demonstrates how implemented reforms can be utilised to enhance our understanding of policy connections in a system of health and social protection. It also increases our understanding of the role of institutional structures in providing care for individuals in different socioeconomic positions. Finally, the findings on impacts of the co-payment increase of non-insulin antidiabetic medicines directly contribute to the assessment of the varied effects of this particular reform in Finland.
To conclude, this study showed that in an interconnected health and social protection system, reforms can have unintended consequences. Due to system-level complementarities, outcomes can also realize in other parts of the system than the one directly affected by the reform. The increased medicine co-payment affected the use of targeted medicines but did not lead to unintended effects in the use of less optimal treatments. The effects were not, however, contained within the reimbursement system. Due to complementarities between the medicine reimbursement and social assistance systems, the probability of social assistance receipt increased after the increase in medicine co-payment. Overall, the prescribing patterns of antidiabetic medicines reflected the changing treatment practices and reimbursement policies. With respect to initiation of novel non-insulin antidiabetic medicines, characteristics of patients in different healthcare sectors paralleled the known cross-sector differences of the Finnish healthcare system. Nevertheless, prior medicine use indicated similar adherence to clinical guidelines of care in all sectors. As such, policy changes of a system that provides care for patients in need should be made only after careful consideration. A deeper understanding of structures, effects, and interplays within the overall health and social protection system can help guide future polices.
Author
Hanna Rättö
Additional Information
- Peer-Reviewed: no.
- Open Access: yes.
- Cite as: Rättö, H. (2024). Impacts of policy changes and the role of institutional structures in healthcare: Exploring outcomes related to the pharmacological care of type 2 diabetes [väitöskirja, Turun yliopisto]. UTUPub. http://www.urn.fi/URN:NBN:fi-fe2024080663831
