Publications

In Press
Daw JR, Hatfield LA. Matching and regression to the mean in difference-in-differences analysis. Health Services Research. In Press.
2017
Daw JR, Sommers BD. Immigration, pregnancy, and heath insurance: New evidence and ongoing debate. Obstetrics & Gynecology [Internet]. 2017;130 (5) :935-937. Publisher's Version
Daw JR, Hatfield LA, Swartz K, Sommers BD. Women in the United States experience high rates of insurance coverage ‘churn’ in months before and after childbirth. Health Affairs [Internet]. 2017;36 (4) :598-606. Publisher's VersionAbstract

Insurance transitions—sometimes referred to as “churn”—before and after childbirth can adversely affect the continuity and quality of care. Yet little is known about coverage patterns and changes for women giving birth in the United States. Using nationally representative survey data for the period 2005–13, we found high rates of insurance transitions before and after delivery. Half of women who were uninsured nine months before delivery had acquired Medicaid or CHIP coverage by the month of delivery, but 55 percent of women with that coverage at delivery experienced a coverage gap in the ensuing six months. Risk factors associated with insurance loss after delivery include not speaking English at home, being unmarried, having Medicaid or CHIP coverage at delivery, living in the South, and having a family income of 100–185 percent of the poverty level. To minimize the adverse effects of coverage disruptions, states should consider policies that promote the continuity of coverage for childbearing women, particularly those with pregnancy-related Medicaid eligibility.

2016
Edelstein CA, Daw JR, Kassam Z. Seeking safe stool: Canada needs a universal donor model. Canadian Medical Association Journal [Internet]. 2016;188 (16-17) :E431-432. . Publisher's Version
2015
Edelstein CA, Kassam Z, Daw JR, Smith MB, Kelly CR. The regulation of fecal microbiota for transplantation: An international perspective for policy and public health. Clinical Research and Regulatory Affairs [Internet]. 2015 :1-9. Publisher's VersionAbstract

Clostridium difficile is the most common hospital-acquired pathogen in the US, and recurrent C. difficile infection (CDI) is a major public health issue. Twenty per cent of CDI patients experience recurrence, and their risk of recurrence rises with each failure to achieve clinical resolution. Fecal microbiota transplantation (FMT) is a remarkably efficacious treatment for recurrent CDI. However, national health agencies are grappling with the appropriate regulatory paradigm to apply to this innovative treatment. Current FMT regulations in the US, Canada, Western Europe, Australia, and China are in varying degrees of flux, although many regulators are choosing to apply the drug and biologic framework. FMT regulations should allow recurrent CDI patients safe access to this treatment as research continues. Regulating FMT like a drug or biologic, although most convenient from a legal perspective, overly restricts access while under-regulating the methods by which the stool is screened, processed, stored, and used. Human tissue and tissue-based products regulations could achieve the desired level and kind of oversight, but fecal microbiota for transplantation fail to meet applicable statutory definitions. A custom regulatory solution would be more appropriate, but many pathways that regulators may take to achieve this goal require time and resources for health agencies to develop.

Morgan SG, Law MR, Daw JR, Abraham L, Martin D. Estimated cost of universal public coverage of prescription drugs in Canada. Canadian Medical Association Journal [Internet]. 2015;187 :491-497. Publisher's VersionAbstract

Background: With the exception of Canada, all countries with universal health insurance systems provide universal coverage of prescription drugs. Progress toward universal public drug coverage in Canada has been slow, in part because of concerns about the potential costs. We sought to estimate the cost of implementing universal public coverage of prescription drugs in Canada.

Methods: We used published data on prescribing patterns and costs by drug type, as well as source of funding (i.e., private drug plans, public drug plans and out-of-pocket expenses), in each province to estimate the cost of universal public coverage of prescription drugs from the perspectives of government, private payers and society as a whole. We estimated the cost of universal public drug coverage based on its anticipated effects on the volume of prescriptions filled, products selected and prices paid. We selected these parameters based on current policies and practices seen either in a Canadian province or in an international comparator.

Results: Universal public drug coverage would reduce total spending on prescription drugs in Canada by $7.3 billion (worst-case scenario $4.2 billion, best-case scenario $9.4 billion). The private sector would save $8.2 billion (worst-case scenario $6.6 billion, best-case scenario $9.6 billion), whereas costs to government would increase by about $1.0 billion (worst-case scenario $5.4 billion net increase, best-case scenario $2.9 billion net savings). Most of the projected increase in government costs would arise from a small number of drug classes.

Interpretation: The long-term barrier to the implementation of universal pharmacare owing to its perceived costs appears to be unjustified. Universal public drug coverage would likely yield substantial savings to the private sector with comparatively little increase in costs to government.

2014
Morgan SG, Daw JR, Law MR. Are income-based public drug benefit programs fit for an aging population?. Montreal, QC: Institute for Research on Public Policy; 2014. Publisher's VersionAbstract

Medications prescribed outside a hospital setting are not covered by Canada’s medicare system. They are financed through a patchwork of private and public drug insurance plans that only provide coverage for select populations, leaving many Canadians with little or no coverage.

Up until the late 1990s, people 65 and older received universal, almost first-dollar public drug coverage in most provinces. But with population aging, the public liability associated with age entitlements has become a major concern for governments. Four provinces have discontinued their age-based programs, which covered most of the cost of medications for seniors, and -replaced them with income-based programs, which protect all residents against catastrophic drug costs. Other provinces have started to move or are considering moving in this direction.

Is this sound policy? Steven Morgan, Jamie Daw and Michael Law assess the performance of -income-based public drug plans against three key policy objectives: access, equity and efficiency. They review the theory and the evidence by comparing Ontario’s age-based and British Columbia’s income-based systems. They find that income-based plans perform poorly with respect to all of these objectives.

First, replacing age-based public plans with income-based drug benefit plans reduces seniors’ access to necessary medicines. The deductibles are a financial disincentive for patients to fill -needed prescriptions and they therefore reduce their adherence to the prescribed therapy. Second, it raises important equity issues. Deductibles under income-based plans impose considerable direct costs, especially on seniors, who are more likely to be high-needs users of prescription drugs. Third, income-based programs undermine cost efficiency because a large share of the residual costs falls to employers, unions and patients. Having multiple payers increases administrative costs and fails to leverage the purchasing power of government as the single payer in the pharmaceutical market place.

Policy-makers have portrayed the adoption of income-based plans as an expansion of previous programs because income-based plans cover patients of all ages, not just seniors. The authors of this study argue that what this really represents is a retrenchment of public drug benefits in Canada.

The authors recommend moving to public plans that offer full and universal coverage of prescription drug costs, financed through personal income taxes. Such plans would ensure better access, equity and efficiency than do those built around income-based deductibles. In particular, they would provide more equitable coverage for high-needs prescription-drug users. This approach would also enable government to achieve greater cost efficiencies and improve health outcomes. As the single payer, government would be better able to lower the price of brand-name and generic drugs, promote the use of generic drugs, help improve prescribing patterns, and take advantage of administrative and other cost efficiencies.

Daw JR, Morgan SG, Collins PA, Abelson J. Framing Incremental Expansions to Public Health Insurance Systems: The Case of Canadian Pharmacare. Journal of Health Politics, Policy and Law [Internet]. 2014;39 :295–330. Publisher's VersionAbstract
Canada is the only country in the world to offer universal comprehensive public health insurance that excludes outpatient prescription medicines. Few scholars have attempted to explain this policy puzzle. We study media coverage of prescription drug financing from 1990 to 2010 to elucidate how the policy problem and potential solutions have been framed in media discourse and identify the actors that have dominated media texts. We confirm previous analyses that have revealed the significant role played by policy elites in media coverage of health reform debates. We also find that proposed expansions to public coverage are presented as a financial liability that could “crowd out” the existing (and popular) public insurance program. Within the context of a predominantly public funded system, framing of incremental expansion reorients away from values and toward discourse related to costs — both of the current system and of potential reforms. This may reflect a strategic narrative used by actors to maintain “silos of values” for coverage for prescription medicines versus those for other services. This has significant implications for the motivation for reform among the electorate and politicians alike, and for the extent to which policy developments, if they occurred, would legitimately reflect societal values for health financing.
Morgan S, Daw JR, Thomson PA. Pharmaceuticals. In: Marchildon GP, Di Matteo L Bending the Cost Curve in Health Care: Canada’s Provinces in International Perspective. Toronto: University of Toronto Press ; 2014. Publisher's VersionAbstract

Bending the Cost Curve in Health Care offers domestic and international perspectives on the management of ever growing health costs. The objective of the book is to get beyond the sterile debates of the past decade and to try to determine where Canada sits, and should sit, in terms of its health care cost curve, in comparison to other OECD countries.

Leading experts from around the world and from a range of disciplines and professional backgrounds lay out the problems faced by policy-makers and provide international case studies from the UK, Norway, the United States, Australia, and Asia. Provincial experiences within Canada are explored in depth, and analyses of pan-Canadian issues such as pharmaceuticals and public-sector health spending address the question of the sustainability of health care in Canada.

2013
Morgan SG, Thomson PA, Daw JR, Friesen MK. Canadian policy makers’ views on pharmaceutical reimbursement contracts involving confidential discounts from drug manufacturers. Health Policy [Internet]. 2013;112 :248–254. Publisher's VersionAbstract
Pharmaceutical policy makers are increasingly negotiating reimbursement contracts that include confidential price terms that may be affected by drug utilization volumes, patterns, or outcomes. Though such contracts may offer a variety of benefits, including the ability to tie payment to the actual performance of a product, they may also create potential policy challenges. Through telephone interviews about this type of contract, we studied the views of officials in nine of ten Canadian provinces. Use of reimbursement contracts involving confidential discounts is new in Canada and ideas about power and equity emerged as cross-cutting themes in our interviews. Though confidential rebates can lower prices and thereby increase coverage of new medicines, several policy makers felt they had little power in the decision to negotiate rebates. Study participants explained that the recent rise in the use of rebates had been driven by manufacturers’ pricing tactics and precedent set by other jurisdictions. Several policy makers expressed concerns that confidential rebates could result in inter-jurisdictional inequities in drug pricing and coverage. Policy makers also noted un-insured and under-insured patients must pay inflated “list prices” even if rebates are negotiated by drug plans. The establishment of policies for disciplined negotiations, inter-jurisdictional cooperation, and provision of drug coverage for all citizens are potential solutions to the challenges created by this new pharmaceutical pricing paradigm.
Puyat JH, Daw JR, Cunningham CM, Law MR, Wong ST, Greyson DL, Morgan SG. Racial and ethnic disparities in the use of antipsychotic medication: a systematic review and meta-analysis. Social Psychiatry and Psychiatric Epidemiology [Internet]. 2013;48 :1861–1872. Publisher's VersionAbstract
Objective To conduct a systematic review and meta-analysis of published evidence on ethnic or racial disparities in the outpatient use versus non-use of antipsychotics and in the outpatient use of newer versus older antipsychotics. Method Electronic databases were searched for potentially relevant studies. Two independent reviewers conducted the review in three stages: title review, abstract review and full-text review. Included studies were those that: (a) report measures of disparity in the outpatient use of antipsychotic drugs in clearly defined racial or ethnic groups (b) have a primary focus on ethnic or racial disparities, and (c) have adjusted for factors known to influence medicine use. Odds ratios were pooled following the inverse-variance method of weighting effect sizes. I 2 statistics were calculated to quantify the amount of variation that is likely due to heterogeneity between studies. Funnel plots were produced and Egger’s statistic was calculated to assess potential publication bias. Results No significant differences were found in the odds of using any antipsychotics among African Americans ({OR} = 1.01, {CI} = 0.99–1.02) compared with non-African Americans and among Latinos ({OR} = 0.98, {CI} = 0.86–1.13) compared with non-Latinos. Small to moderate but statistically non-significant disparities were also noted in other ethnic groups: Asians ({OR} = 1.10, {CI} = 0.88–1.36), Maoris ({OR} = 0.78, {CI} = 0.53–1.13) and Pacific Islanders ({OR} = 0.97, {CI} = 0.84–1.11). Among those who received antipsychotic medication, African Americans ({OR} = 0.62, {CI} = 0.50–0.78) and Latinos ({OR} = 0.77, {CI} = 0.73–0.81) appeared to have lower odds of receiving newer antipsychotics compared with non-African Americans and non-Latinos. Conclusion No significant ethnic disparities in the use versus non-use of any antipsychotics were observed, but, among those who received antipsychotic treatment, ethnic minorities were consistently less likely than non-ethnic minorities to be treated with newer antipsychotics.
Morgan SG, Friesen MK, Thomson PA, Daw JR. Use of Product Listing Agreements by Canadian Provincial Drug Benefit Plans. Healthcare Policy [Internet]. 2013;8 :45–55. Publisher's VersionAbstract
{Background: Product listing agreements ({PLAs}) between drug manufacturers and drug plans are increasingly common worldwide. Use of {PLAs} by Canadian provinces has not previously been documented. Methods: We collected data from all provinces on funding and {PLA} use for 25 drugs that were reviewed by the Common Drug Review ({CDR}) in 2010 or 2011 and funded by at least one province as of May 2012. We measured correlations between coverage and {PLA} use, and {CDR} recommendations and {PLA} use. Results: The number of drugs from our sample funded by provinces ranged from three in Prince Edward Island to 21 in Ontario. {PLA} use ranged from zero in Quebec, Prince Edward Island, and Newfoundland and Labrador to 20 in Ontario. The correlation between drugs funded and {PLAs} used by each province was statistically significant (r=0.57
Law MR, Daw JR, Cheng L, Morgan SG. Growth in private payments for health care by Canadian households. Health Policy [Internet]. 2013;110 :141–146. Publisher's VersionAbstract
Introduction Despite first-dollar public coverage for hospital and physician services, Canadians spend more privately on health care than citizens of most other developed countries. We quantified recent growth in private payments by Canadian households for health care. Methods Using data from 163,081 respondents to Statistics Canada's annual Survey of Household Spending from 1998 to 2009, we calculated inflation-adjusted per-household spending on private health insurance premiums and out-of-pocket payments on six types of health care services. Further, we estimated the prevalence and some socio-economic determinants of households spending over 10% of after-tax income on health care using logistic regression. Results We found that Canadian households spent \$19.8 billion on private payments for health care in 2009. This represents an average of \$1523 per household—a 37% increase over 1998. The top three spending categories in 2009 were private health insurance premiums (\$5.9 billion), dental (\$4.9 billion) and prescription drugs (\$4.2 billion). Even after adjusting for inflation, expenditure on every category of health care spending increased between 1998 and 2009. The proportion of households spending more than 10% of after-tax income on health care increased by 56% (from 3.3% to 5.2%). Households including a senior, with a low income, and in British Columbia or the Atlantic Provinces were significantly more likely to reach this threshold. Interpretation Over the period studied, the burden of private health care expenditures increased substantially for Canadian households. As direct charges reduce the use of necessary health care services, investigation into the health consequences of these increases is warranted.
Daw JR, Morgan SG, Thomson PA, Law MR. Here today, gone tomorrow: The issue attention cycle and national print media coverage of prescription drug financing in Canada. Health Policy [Internet]. 2013;110 :67–75. Publisher's VersionAbstract
Canada is the only developed country that has established universal coverage for hospital care and physician services that excludes medically necessary prescription drugs. Lack of public interest in expanding universal coverage to prescription medicines may be one critical factor in explaining this policy puzzle. Historical levels and patterns of attention to financing issues in the media may have implications for public awareness and support for such major health reform. We thus examined the quantity, context, and patterns of coverage of public drug financing in national print media in Canada from 1990 to 2010. We conducted a time series analysis of monthly newspaper article counts to quantify trends in coverage and analyzed article content by applying Down's theory of the “issue-attention cycle” of political attention. We found that baseline coverage of this issue was low throughout the past twenty years with few cycles of increased attention, initiated by focusing events related to general health reform. Issue-attention cycles were driven by coverage of proposed policy solutions simultaneously accompanied by lower levels of coverage of policy problems and barriers to change, before fading rapidly from attention. The observed patterns of media coverage and the intrinsic characteristics of this policy issue suggest that any momentum for reform (or lack thereof) is likely to be driven by elite members of the policy community rather than by way of public engagement. This has implications for the probability of reform and which options may be considered or eventually implemented, as policies developed within elite policy communities may tend to reflect niche interests rather than being reflective of principled policy goals.
Morgan S, Daw J, Thomson P. International Best Practices For Negotiating ‘Reimbursement Contracts’ With Price Rebates From Pharmaceutical Companies. Health Affairs [Internet]. 2013;32 :771–777. Publisher's VersionAbstract
Reimbursement contracts, in which health insurers receive rebates from drug manufacturers instead of paying the transparent list price, are becoming increasingly common worldwide. Through interviews with policy makers in nine high-income countries, we describe the use of these contracts around the globe and identify related policy challenges and best practices. Of the nine countries surveyed, the majority routinely use confidential reimbursement contracts. This alternative to drug coverage at list prices offers benefits but is not without challenges. Payers face increased administrative costs, difficulties enforcing contracts, and reduced information about prices paid by others. Among the best practices identified, policy makers recommend establishing clear and consistent processes for negotiating contracts with relatively simple rebate structures and transparency to the public about the existence, purpose, and type of reimbursement contracts in place. Policy makers should also work to address undesirable price disparities within their countries and internationally, which may occur as a result of this new pricing paradigm.
Morgan S, Daw JR, Law MR. Rethinking Pharmacare in Canada. C.D. Howe Institute; 2013. Publisher's Version
Morgan SG, Thomson PA, Daw JR, Friesen MK. Inter-jurisdictional cooperation on pharmaceutical product listing agreements: views from Canadian provinces. BMC Health Services Research [Internet]. 2013;13 :34. Publisher's VersionAbstract

Confidential product listing agreements negotiated between pharmaceutical manufacturers and individual health care payers may contribute to unwanted price disparities, high administrative costs, and unequal bargaining power within and across jurisdictions. In the context of Canada’s decentralized health system, we aimed to document provincial policy makers’ perceptions about collaborative PLA negotiations. 

2012
Morgan SG, Daw JR. Canadian Pharmacare: Looking Back, Looking Forward. Healthcare Policy [Internet]. 2012;8 :14–23. Publisher's VersionAbstract
Despite Canadians' pride in medicare and the values underpinning it, the system is conspicuously incomplete. Universal public health insurance in Canada ends as soon as a patient is handed a prescription to fill; yet prescription drugs are the second largest component of health system costs. We look back at key moments in Canadian healthcare history that shaped our pharmacare system – or lack thereof. We look forward to changes in demography and technology that will increase the need for pharmacare reform in the near future. We conclude that meaningful public engagement in pharmacare design may generate the clarity of goals and level of political support needed should windows of policy opportunity open again.
Daw JR, Mintzes B, Law MR, Hanley GE, Morgan SG. Prescription Drug Use in Pregnancy: A Retrospective, Population-Based Study in British Columbia, Canada (2001–2006). Clinical Therapeutics [Internet]. 2012;34 :239–249.e2. Publisher's VersionAbstract
Background Owing to the paucity of evidence available on the risks and benefits of drug use in pregnancy, the use of prescription medicines is a concern for both pregnant women and their health care providers. Objective The aim of this study was to measure the frequency, timing, and type of medicines used before, during, and after pregnancy in a Canadian population. Methods This retrospective cohort analysis used population-based health care data from all pregnancies ending in live births in hospitals in British Columbia from April 2001 to June 2006 (n = 163,082). Data from hospital records were linked to those in outpatient prescription-drug claims. Data from prescriptions filled from 6 months before pregnancy to 6 months postpartum were analyzed. Drugs were classified by therapeutic category and {US} Food and Drug Administration ({FDA}) pregnancy risk categories. Results Prescriptions were filled in 63.5% of pregnancies. Evidence on safety is limited for many of the medicines most frequently filled in pregnancy, including codeine, salbutamol, and betamethasone. At least 1 prescription for a category D or X medicine was filled in 7.8% of pregnancies (5.5% category D; 2.5% category X). The most frequently filled prescriptions for category D drugs were benzodiazepines and antidepressants. The most frequently filled prescriptions for category X drugs were oral contraceptives and ovulation stimulants filled in the first trimester. Conclusions The majority of pregnant women in British Columbia filled at least 1 prescription, and ∼1 in 13 filled a prescription for a drug categorized as D or X by the {FDA}. The prevalence of maternal prescription drug use emphasizes the need for postmarketing evaluation of the risk–benefit profiles of pharmaceuticals in pregnancy. Future research on prenatal drug use based on administrative databases should examine maternal treatment adherence and the determinants of maternal drug use, considering maternal health status, sociodemographics, and the characteristics and providers of prenatal care.
Daw JR, Morgan SG. Stitching the gaps in the Canadian public drug coverage patchwork? A review of provincial pharmacare policy changes from 2000 to 2010. Health Policy [Internet]. 2012;104 :19–26. Publisher's VersionAbstract
Objectives To describe recent changes and identify emergent trends in public drug benefit policies in Canada from 2000 to 2010. Methods For each province, we tracked pharmacare design (namely eligibility, premiums, and patient cost-sharing) over time for three beneficiary groups: social assistance recipients, seniors, and the general non-senior population. We assess which plan designs are emerging as a national standard, where the gaps in public coverage remain, and implications for progress towards national pharmacare. Results Expansion of public drug coverage has been limited. For social assistance recipients, first-dollar coverage is the standard. Seniors coverage remains varied, though means testing of eligibility or cost-sharing is common. Seniors benefits were significantly expanded in only one province. As of 2010, six provinces have embraced age irrelevant catastrophic income-based coverage, in some, resulting in the elimination of seniors drug benefits. Conclusions Universal income-based catastrophic coverage appears to be emerging as an implicit national standard for provincial pharmacare. However, due to the variation and high level of patient cost-sharing required under these programs, convergence on this model does not equate to substantial progress towards expanding coverage or reducing interprovincial disparities. Leverage of federal spending power to promote standards for public drug coverage is necessary to uniformly protect Canadians against high drug costs.

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