{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T22:41:35Z","timestamp":1773355295772,"version":"3.50.1"},"reference-count":33,"publisher":"BMJ","issue":"11","funder":[{"name":"Insituto de Salud Carlos III. Spanish Healh Ministry"},{"name":"Sociedad Econ\u00f3mica Barcelonesa de Amigos del Pa\u00eds"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["BMJ Qual Saf"],"accepted":{"date-parts":[[2018,2,11]]},"published-print":{"date-parts":[[2018,11]]},"abstract":"<jats:sec>\n                  <jats:title>Objective<\/jats:title>\n                  <jats:p>Copayment policies aim to reduce the burden of medication expenditure but may affect adherence and generate inequities in access to healthcare. The objective was to evaluate the impact of two copayment measures on initial medication non-adherence (IMNA) in several medication groups and by income level.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Design<\/jats:title>\n                  <jats:p>A population-based study was conducted using real-world evidence.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Setting<\/jats:title>\n                  <jats:p>Primary care in Catalonia (Spain) where two separate copayment measures (fixed copayment and coinsurance) were introduced between 2011 and 2013.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Participant<\/jats:title>\n                  <jats:p>Every patient with a new prescription issued between 2011 and 2014 (3 million patients and 10\u2009million prescriptions).<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Outcomes<\/jats:title>\n                  <jats:p>IMNA was estimated throughout dispensing and invoicing information. Changes in IMNA prevalence after the introduction of copayment policies (immediate level change and trend changes) were estimated through segmented logistic regression. The regression models were stratified by economic status and medication groups.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Before changes to copayment policies, IMNA prevalence remained stable. The introduction of a fixed copayment was followed by a statistically significant increase in IMNA in poor population, low\/middle-income pensioners and low-income non-pensioners (OR from 1.047 to 1.370). In high-income populations, there was a large statistically non-significant increase. IMNA decreased in the low-income population after suspension of the fixed copayment and the introduction of a coinsurance policy that granted this population free access to medications (OR=0.676). Penicillins were least affected while analgesics were affected to the greatest extent. IMNA to medications for chronic conditions increased in low\/middle-income pensioners.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Even nominal charge fixed copayment may generate inequities in access to health services. An anticipation effect and expenses associated with IMNA may have generated short-term costs. A reduction in copayment can protect from non-adherence and have positive, long-term effects. Copayment scenarios could have considerable long-term consequences for health and costs due to increased IMNA in medication for chronic physical conditions.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/bmjqs-2017-007416","type":"journal-article","created":{"date-parts":[[2018,3,15]],"date-time":"2018-03-15T12:20:24Z","timestamp":1521116424000},"page":"878-891","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":28,"title":["Effect of copayment policies on initial medication non-adherence according to income: a population-based study"],"prefix":"10.1136","volume":"27","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6780-5968","authenticated-orcid":false,"given":"Ignacio","family":"Aznar-Lou","sequence":"first","affiliation":[{"name":"Research and Development Unit, Institut de Recerca Sant Joan de D\u00e9u, Barcelona, Catalonia, Spain"},{"name":"Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Anton","family":"Potteg\u00e5rd","sequence":"additional","affiliation":[{"name":"Department of Clinical Pharmacology, University of Southern Denmark, Odense, Denmark"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ana","family":"Fern\u00e1ndez","sequence":"additional","affiliation":[{"name":"Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain"},{"name":"Service of Community Health, Public Health Agency of Barcelona, Barcelona, Catalonia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Mar\u00eda Teresa","family":"Pe\u00f1arrubia-Mar\u00eda","sequence":"additional","affiliation":[{"name":"Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain"},{"name":"Institut Catal\u00e0 de la Salut, Barcelona, Catalunya, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Antoni","family":"Serrano-Blanco","sequence":"additional","affiliation":[{"name":"Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain"},{"name":"Research and Development Unit, Parc Sanitari Sant Joan de D\u00e9u, Barcelona, Catalonia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Ram\u00f3n","family":"Sab\u00e9s-Figuera","sequence":"additional","affiliation":[{"name":"Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain"},{"name":"Faculty of Economics and Business Science, Universitat Pompeu Fabra, Barcelona, Catalonia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Montserrat","family":"Gil-Girbau","sequence":"additional","affiliation":[{"name":"Research and Development Unit, Institut de Recerca Sant Joan de D\u00e9u, Barcelona, Catalonia, Spain"},{"name":"Primary Care Prevention and Health Promotion Research Network, Barcelona, Catalonia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marta","family":"Faj\u00f3-Pascual","sequence":"additional","affiliation":[{"name":"Faculty of Health and Sport Sciences, University of Zaragoza, Huesca, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patricia","family":"Moreno-Peral","sequence":"additional","affiliation":[{"name":"Distrito de Atenci\u00f3n Primaria M\u00e1laga-Guadalhorce, M\u00e1laga, Spain"},{"name":"IBIMA, M\u00e1laga, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Maria","family":"Rubio-Valera","sequence":"additional","affiliation":[{"name":"Research and Development Unit, Institut de Recerca Sant Joan de D\u00e9u, Barcelona, Catalonia, Spain"},{"name":"Centro de Investigacion Biomedica en Red de Epidemiologia y Salud Publica, Barcelona, Catalunya, Spain"},{"name":"School of Pharmacy, University of Barcelona, Barcelona, Catalonia, Spain"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"239","published-online":{"date-parts":[[2018,3,15]]},"reference":[{"key":"2025090412595119000_27.11.878.1","unstructured":"OECD. 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