Value-Based Insurance Design: Quality Improvement But No Cost Savings

Reduced Cost Sharing and Medication Management Services for COPD: A Randomized Clinical Trial

Importance

High out-of-pocket costs and improper use of maintenance inhalers contribute to poor outcomes among patients with chronic obstructive pulmonary disease (COPD). There is limited evidence for how addressing these barriers could improve adherence and affect COPD exacerbations, spending, or racial disparities in these outcomes.

Objective

To examine the effect of a national program to reduce beneficiary cost sharing for COPD maintenance inhalers and provide medication management services that included education on proper technique for inhaler use.

Design, Setting, and Participants

This randomized clinical trial included individuals with COPD. All individuals were enrolled in Medicare Advantage. Data were collected from January 2019 to December 2021, and data were analyzed from January 2023 to May 2024.

Intervention

Invitation to enroll in a program that reduced cost sharing for maintenance inhalers to $0 or $10 and provided medication management services. The random assignment of the invitation was used to estimate the effects of the invitation and program enrollment, overall and by race.

Main Outcomes and Measures

Inhaler adherence measured as proportion of days covered (PDC), moderate-to-severe exacerbations, short-acting inhaler fills, total spending, and as an exploratory outcome, out-of-pocket spending.

Results

Of 19 113 included patients, 55.2% were female; 9.5% were Black, 81.1% were White, and 9.4% were another or unknown race; and the median (IQR) age was 74 (69-80) years. Program enrollment was higher in the invited group (29.4%) than the control group (5.1%). The PDC for maintenance inhalers was higher in the invited group than the control group (32.0% vs 28.4%; adjusted invitation effect, 3.8 percentage points; 95% CI, 3.1-4.5); the adjusted effect of the program (the local average treatment effect) was 15.5 percentage points (95% CI, 12.8-18.1), a 55% relative increase in adherence. Mean (SD) out-of-pocket spending for prescriptions was lower in the invited group ($619.5 [$863.1]) than the control group ($675.0 [$887.3]; adjusted invitation effect, -$49.5; 95% CI, -68.9 to -30.0; adjusted program effect, -$203.0; 95% CI, -282.8 to -123.2), but there was no statistically significant difference in exacerbations, short-acting inhaler fills, or total spending. Among Black individuals, the adjusted invitation effect on maintenance inhaler PDC was 5.5 percentage points (95% CI, 3.3-7.7), and the adjusted program effect was 19.5 percentage points (95% CI, 12.4-26.7). Among White individuals, the adjusted invitation effect was 3.7 percentage points (95% CI, 2.9-4.4), and the adjusted program effect was 15.1 percentage points (95% CI, 12.1-18.1). The difference between the invitation effects by race was not statistically significant (1.8 percentage points; 95% CI, -0.5 to 4.1; P = .13).

Conclusions and Relevance

Individuals in Medicare Advantage who received an invitation to enroll in a program that reduced cost sharing for maintenance inhalers and provided medication management services had higher inhaler adherence compared with the control group. The difference in the program's effect on inhaler adherence between Black and White individuals was substantial but not statistically significant.

Trial Registration

ClinicalTrials.gov Identifier: NCT05497999.

The Impact of Prescription Drug Coverage on Disparities in Adherence and Medication Use: A Systematic Review

Prescription drug cost-sharing is a barrier to medication adherence, particularly for low-income and minority populations. In this systematic review, we examined the impact of prescription drug cost-sharing and policies to reduce cost-sharing on racial/ethnic and income disparities in medication utilization. We screened 2,145 titles and abstracts and identified 19 peer-reviewed papers that examined the interaction between cost-sharing and racial/ethnic and income disparities in medication adherence or utilization. We found weak but inconsistent evidence that lower cost-sharing is associated with reduced disparities in adherence and utilization, but studies consistently found that significant disparities remained even after adjusting for differences in cost-sharing across individuals. Study designs varied in their ability to measure the causal effect of policy or cost-sharing changes on disparities, and a wide range of policies were examined across studies. Further research is needed to identify the types of policies that are best suited to reduce disparities in medication adherence.

Implementation Strategies to Improve Blood Pressure Control in the United States: A Scientific Statement From the American Heart Association and American Medical Association

Hypertension is one of the most important risk factors that contribute to incident cardiovascular events. A multitude of US and international hypertension guidelines, scientific statements, and policy statements have recommended evidence-based approaches for hypertension management and improved blood pressure (BP) control. These recommendations are based largely on high-quality observational and randomized controlled trial data. However, recent published data demonstrate troubling temporal trends with declining BP control in the United States after decades of steady improvements. Therefore, there is a widening disconnect between what hypertension experts recommend and actual BP control in practice. This scientific statement provides information on the implementation strategies to optimize hypertension management and to improve BP control among adults in the United States. Key approaches include antiracism efforts, accurate BP measurement and increased use of self-measured BP monitoring, team-based care, implementation of policies and programs to facilitate lifestyle change, standardized treatment protocols using team-based care, improvement of medication acceptance and adherence, continuous quality improvement, financial strategies, and large-scale dissemination and implementation. Closing the gap between scientific evidence, expert recommendations, and achieving BP control, particularly among disproportionately affected populations, is urgently needed to improve cardiovascular health.

Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans

Importance

High-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown.

Objective

To evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma.

Design, Setting, and Participants

This case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023.

Exposures

Employer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA.

Main Outcomes and Measures

Outcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific).

Results

A total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting β2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, -$34 [95% CI, -$47 to -$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income.

Conclusions and Relevance

In this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.

Association of Participation in a Value-Based Insurance Design Program With Health Care Spending and Utilization

Importance

Value-based insurance design (VBID) has mostly been used in improving medication use and adherence for certain conditions or patients, but its outcomes remain uncertain when applied to other services and to all health plan enrollees.

Objective

To determine the association of participation in a California Public Employees' Retirement System (CalPERS) VBID program with its enrollees' health care spending and utilization.

Design, Setting, and Participants

A retrospective cohort study with difference-in-differences propensity-weighted 2-part regression models was performed in 2021 to 2022. A VBID cohort was compared with a non-VBID cohort both before and after VBID implementation in California in 2019 with 2 years' follow-up. The study sample included CalPERS preferred provider organization continuous enrollees from 2017 through 2020. Data were analyzed from September 2021 to August 2022.

Exposures

The key VBID interventions include (1) if selecting and using a primary care physician (PCP) for routine care, PCP office visit copayment is $10 (otherwise, PCP office visit copayment is $35 as for specialist visit); and (2) annual deductibles reduced by a half through completion of the following 5 activities: annual biometric screening, influenza vaccine, nonsmoking certification, second opinion for elective surgical procedures, and disease management participation.

Main Outcomes and Measures

The primary outcome measures included annual per member total approved payments for multiple inpatient and outpatient services.

Results

The 2 compared cohorts of 94 127 participants (48 770 were female [52%]; 47 390 were younger than 45 years old [50%]) had insignificant baseline differences after propensity-weighting adjustment. The VBID cohort had significantly lower probabilities of inpatient admissions (adjusted relative odds ratio [OR], 0.82; 95% CI, 0.71-0.95), and higher probabilities of receiving immunizations (adjusted relative OR, 1.07; 95% CI, 1.01-1.21) in 2019. Among those with positive payments, VBID was associated with higher mean total allowed amounts for PCP visits in 2019 and 2020 (adjusted relative payments ratio, 1.05; 95% CI, 1.02-1.08). There were no significant differences for inpatient and outpatient combined totals in 2019 and 2020.

Conclusions and Relevance

The CalPERS VBID program achieved desired goals for some interventions with no added total costs in its first 2 years of operation. VBID may be used to promote valued services while containing costs for all enrollees.

Understanding patient cost-sharing thresholds for diabetes treatment attributes via a discrete choice experiment

BACKGROUND: The process used to prefer certain products across drug classes for diabetes is generally focused on comparative effectiveness and cost. However, payers rarely tie patient preference for treatment attributes to formulary management resulting in a misalignment of value defined by providers, payers, and patients. OBJECTIVES: To explore patients' willingness to pay (WTP) for the predetermined high-value and low-value type 2 diabetes mellitus (T2DM) treatments within a health plan. METHODS: A cross-sectional discrete choice experiment (DCE) survey was used to determine patient preference for the benefit, risk, and cost attributes of T2DM treatments. A comprehensive literature review of patient preference studies in diabetes and a review of guidelines and medical literature identified study attributes. Patients and diabetes experts were interviewed and instructed to identify, prioritize, and comment on which attributes of diabetes treatments were most important to T2DM patients. The patients enrolled in a health plan were asked to respond to the survey. A multinomial logit model was developed to determine the relative importance and the patient's WTP of each attribute. The patients' relative values based on WTPs for T2DM treatments were calculated and compared with the treatments by a health plan. RESULTS: A total of 7 attributes were selected to develop a web-based DCE questionnaire survey. The responses from a total of 58 patients were analyzed. Almost half (48.3%) of the respondents took oral medications and injections for T2DM. The most prevalent side effects due to diabetes medications were gastrointestinal (43.1%), followed by weight gain (39.7%) and nausea (32.8%). Patients were willing to pay more for treatments with proven cardiovascular benefit and for the risk reduction of hospitalization from heart failure. On the other hand, they would pay less for treatments with higher gastrointestinal side effects. Patients were willing to pay the most for sodium-glucose cotransporter 2 inhibitor and glucagon-like peptide 1 receptor agonist agents and the least for dipeptidyl peptidase-4 inhibitors and thiazolidinediones. CONCLUSIONS: This study provides information to better align patient, provider, and payer preferences in both benefit design and value-based formulary strategy for diabetes treatments. A preferred placement of treatments with cardiovascular benefits and lower adverse gastrointestinal side effects may lead to increased adherence to medications and improved clinical outcomes at a lower overall cost to both patients and their health plan. DISCLOSURES: This study was supported by a grant from the PhRMA Foundation.

The Design of the RAND Health Insurance Experiment: A Retrospective

This article, prepared as part of a special issue on multiarmed experiments, describes the design of the RAND Health Insurance Experiment, paying particular attention to the choice of arms. It also describes how the results of the Experiment were used in a simulation model and, looking back, how the design might have differed, and how the results apply today, 4 decades after the Experiment was conducted.

Does the diabetes health plan have a differential impact on medication adherence among beneficiaries with fewer financial resources?

BACKGROUND: The Diabetes Health Plan (DHP), a value-based insurance plan that reduces cost sharing, was previously shown to modestly increase employer-level medication adherence. It is unclear how the DHP might impact individuals with different incomes. OBJECTIVE: To examine the impact of the DHP on individual-level medication adherence, by income level. METHODS: This is a retrospective, quasiexperimental study. An employer-level propensity score match was done to identify suitable control employers, followed by individual-level propensity score weighing. These weights were applied to difference-in-difference models examining the effect of the DHP and the effect of income on changes in adherence to metformin, statins, and angiotensin-converting enzymes/angiotensin receptor blockers. The weights were then applied to a differences-in-differences-in-differences model to estimate the differential impact of DHP status on changes in adherence by income group. RESULTS: The study population included 2,065 beneficiaries with DHP and 17,704 matched controls. There were no significant differences in changes to adherence for any medications between beneficiaries enrolled in the DHP vs standard plans. However, adherence to all medications was higher among those with incomes greater than $75,000 (year 1: metformin: +7.3 percentage points; statin +4.3 percentage points; angiotensin-converting enzymes/angiotensin receptor blockers: +6.2 percentage points; P < 0.01) compared with those with incomes less than $50,000. The differences-in-differences-in-differences term examining the impact of income on the DHP effect was not significant for any comparisons. CONCLUSIONS: We did not find significant associations between the DHP and changes in individual-level medication adherence, even for low-income beneficiaries. New strategies to improve consumer engagement may be needed to translate value-based insurance designs into changes in patient behavior. DISCLOSURES: Drs Ettner and Moin received grants from the Centers for Disease Control and Prevention and National Institute of Diabetes and Digestive and Kidney Diseases (Principal Investigator: Carol Mangione). Mr Luchs received support for attending meetings and/or travel (minimal-mileage and hotel on 2 occasions). Mr Chan has an employee benefit to purchase stock for UnitedHealth Group.

Do Financial Incentives Affect Utilization for Chronically Ill Medicare Beneficiaries?

OBJECTIVE

The objective of this study was to examine the price sensitivity for provider visits among Medicare Advantage beneficiaries.

DATA SOURCES

We used Medicare Advantage encounter data from 2014 to 2017 accessed as part of an evaluation for the Center for Medicare & Medicaid Innovation.

STUDY DESIGN

We analyzed the effect of cost-sharing on the utilization of 2 outcome categories: number of visits (specialist and primary care) and the probability of any visit (specialist and primary care). Our main independent variable was the size of the copayment for the visit, which we regressed on the outcomes with several beneficiary-level and plan-level control variables.

DATA COLLECTION/EXTRACTION METHODS

We included beneficiaries with at least 1 of 4 specific chronic conditions and matched comparison beneficiaries. We did not require beneficiaries to be continuously enrolled from 2014 to 2017, but we required a full year of data for each year they were observed. This resulted in 371,140 beneficiary-year observations.

PRINCIPAL FINDINGS

Copay reductions were associated with increases in utilization, although the changes were small, with elasticities <-0.2. We also found evidence of substitution effects between primary care provider (PCP) and specialist visits, particularly cardiology and endocrinology. When PCP copays declined, visits to these specialists also declined.

CONCLUSIONS

We find that individuals with chronic conditions respond to changes in copays, although these responses are small. Reductions in PCP copays lead to reduced use of some specialists, suggesting that lowering PCP copays could be an effective way to reduce the use of specialist care, a desirable outcome if specialists are overused.

Employer-Led Strategies to Improve the Value of Health Spending: A Systematic Review

OBJECTIVE

To systematically review studies that evaluated the impact of employer-led efforts in the United States to improve the value of health spending, where employers have implemented changes to their health benefits to reduce costs while improving or maintaining quality.

METHODS

We included all studies of employer-led health benefit strategies that reported outcomes for both employer health spending and employee health outcomes.

RESULTS

Our search returned 44 studies of employer health benefit changes that included measures of both health spending and quality. The most promising efforts were those that lowered or eliminated cost sharing for primary care or medications for chronic illnesses. High deductible health plans with a savings option appeared less promising.

CONCLUSIONS

More research is needed on the characteristics and contexts in which these benefit changes were implemented, and on actions that address employers' current concerns.

How important is income in explaining individuals having forgone healthcare due to cost-sharing payments? Results from a mixed methods sequential explanatory study

Background

Patients having forgone healthcare because of the costs involved has become more prevalent in recent years. Certain patient characteristics, such as income, are known to be associated with a stronger demand-response to cost-sharing. In this study, we first assess the relative importance of patient characteristics with regard to having forgone healthcare due to cost-sharing payments, and then employ qualitative methods in order to understand these findings better.

Methods

Survey data was collected from a Dutch panel of regular users of healthcare. Logistic regression models and dominance analyses were performed to assess the relative importance of patient characteristics, i.e., personal characteristics, health, educational level, sense of mastery and financial situation. Semi-structured interviews (n = 5) were conducted with those who had forgone healthcare. The verbatim transcribed interviews were thematically analyzed.

Results

Of the 7,339 respondents who completed the questionnaire, 1,048 respondents (14.3%) had forgone healthcare because of the deductible requirement. The regression model indicated that having a higher income reduced the odds of having forgone recommended healthcare due to the deductible (odds ratios of higher income categories relative to the lowest income category (reference): 0.29–0.49). However, dominance analyses revealed that financial leeway was more important than income: financial leeway contributed the most (34.8%) to the model’s overall McFadden’s pseudo-R2 (i.e., 0.123), followed by income (25.6%). Similar results were observed in stratified models and in population weighted models. Qualitative analyses distinguished four main themes that affected the patient’s decision whether to use healthcare: financial barriers, structural barriers related to the complex design of cost-sharing programs, individual considerations of the patient, and the perceived lack of control regarding treatment choices within a given treatment trajectory. Furthermore, “having forgone healthcare” seemed to have a negative connotation.

Conclusion

Our findings show that financial leeway is more important than income with respect to having forgone recommended healthcare due to cost-sharing payments, and that other factors such as the perceived necessity of healthcare also matter. Our findings imply that solely adapting cost-sharing programs to income levels will only get one so far. Our study underlines the need for a broader perspective in the design of cost-sharing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07527-z.

Cost implications of patient spending on heart failure medications in the US Medicare program

Objectives

The aim of this study was to model the associations between patient spending on heart failure (HF) medications and Medicare and all-payer expenditures on health care services for participants in the Medicare prescription drug (Part D) program.

Methods

Correlational analysis of pooled 2011–12 data from the Medicare Current Beneficiary Survey. Analysis was restricted to community-dwelling beneficiaries with self-reported HF at baseline, continuous Part D coverage, and no Low-Income Subsidy (LIS). The main predictor was mean patient expenditure on a HF-related prescription per 30-day supply. The outcomes were all-payer and Medicare-specific payments for inpatient and total health care services during the observation year.

Key findings

Mean patient drug expenditure was not statistically associated with Medicare or all-payer inpatient payments or (after covariate adjustment) with total health care payments. However, patient expenditure was statistically associated with total Medicare payments, eγ = 1.022, 95% CI [1.004 to 1.041]. Marginal effects analysis predicted an average rise in total Medicare payments of $190.32, 95% CI [$40.54 to $341.10], for each additional $1 of patient spending per prescription, P = 0.013. Given an average 2.4 HF-indicated drug classes per participant and assuming 12.2 copays per year, a hypothetical $1 increase in prescription copay predicted a net loss to Medicare of $160.90 per participant.

Conclusion

Prescription drug spending by Medicare beneficiaries with HF was not associated with higher inpatient or all-payer costs. A modest association between patient drug spending and total Medicare costs was observed, but longitudinal and cost-effectiveness analyses are needed to support causal inference.

Low-Income Childless Adults' Access To Antidiabetic Drugs In Wisconsin Medicaid After Coverage Expansion

Medicaid coverage was expanded for childless adults in Wisconsin through an amended Section 1115 demonstration waiver on April 1, 2014. Coverage for prescription drugs was expanded via copayment reductions and a drug formulary expansion. We analyzed administrative drug claims data to evaluate changes in the use of and out-of-pocket spending on antidiabetic drugs among childless adults who experienced the drug coverage expansion. Compared to parents or caretakers, who were not affected by the expansion, childless adults experienced a significant increase of 4 percent in the use of antidiabetic drugs-driven mainly by an increase in the population using the drugs, rather than by more intense use. The expanded drug coverage also reduced the burden of out-of-pocket spending for childless adults by 70 percent. Our findings demonstrate that expanding prescription drug benefits led to increased access to antidiabetic drugs for childless adults in Wisconsin Medicaid.

The effect of increased cost-sharing on low-value service use

We examine the effect of a value-based insurance design (VBID) program implemented at a large public employer in the state of Oregon. The program substantially increased cost-sharing for several healthcare services likely to be of low value for most patients: diagnostic services (e.g., imaging services) and surgeries (e.g., spinal surgeries for pain). Using a difference-in-differences design coupled with granular, administrative health insurance claims data over the period 2008-2012, we estimate the change in low-value service use among beneficiaries before and after program implementation relative to a comparison group not exposed to the VBID. Our findings suggest that the VBID significantly reduced the use of targeted services, with an implied elasticity of demand of -0.22. We find no evidence that the VBID led to substitution to non-targeted services or increased overall healthcare costs. However, we also observe no evidence that the program led to cost-savings.

Behavioral Economic Insights to Improve Medication Adherence in Adults with Chronic Conditions: A Scoping Review

BACKGROUND AND OBJECTIVE

Medication adherence is poor in patients with chronic conditions. Behavioral economic interventions may reduce biases that are associated with poor adherence. The objective of this review is to map the available evidence on behavioral economic interventions to improve medication adherence in adults with chronic conditions in high-income settings.

METHODS

We conducted a scoping review and reported the study using the Joanna Briggs Institute Reviewers' Manual and the PRISMA Extension for Scoping Review checklist. We searched PubMed, EMBASE, SCOPUS, PsycINFO, EconLit, and CINAHL from database inception to 29 August, 2018 for peer-reviewed studies and included a search of the gray literature. Data on study characteristics, study design, and study outcomes were extracted by one reviewer. Twenty-five percent of the studies were verified by a second reviewer.

RESULTS

Thirty-four studies, targeting diabetes mellitus, human immunodeficiency virus, and cardiovascular and renal diseases met our inclusion criteria. All but two studies were from the USA. The majority of interventions used financial incentives, often in conjunction with other behavioral economic concepts. Non-financial interventions included framing, social influences, reinforcement, and feedback. The effectiveness of interventions was mixed.

CONCLUSIONS

Behavioral economic informed interventions show promise in terms of improving medication adherence. However, there is no single simple intervention. This review highlighted the importance of targeting non-adherent patients, understanding their reasons for non-adherence, providing reminders and feedback to patients and physicians, and measuring clinical outcomes in addition to medication adherence. Further research in settings that differ from the US health system is needed.

Subsidizing access to prescription drugs and health outcomes: The case of diabetes

This paper evaluates the health effects of a large-scale subsidizing program of prescription drugs introduced in Brazil, the Aqui Tem Farmácia Popular program (ATFP). We exploit features of the program to identify its effects on mortality and hospitalization rates by diabetes for individuals aged 40 years or more. We find weak evidence for a decline in mortality, but a robust reduction in hospitalization rates. According to our preferred specification, an additional ATFP pharmacy per 100,000 inhabitants is associated with a decrease in hospitalization rates by diabetes of 8.2, which corresponds to 3.6% of its baseline rate. Effects are larger for Type II diabetes in comparison to Type I, and among patients with relatively lower socioeconomic status. Overall, the results are consistent with insulin-dependent patients being relatively less responsive to subsidies because of higher immediate life-threatening risks; and with lower-SES individuals being more responsive because of liquidity constraints. These results support the view that the optimal design of health systems and cost-sharing mechanisms should take into account equity concerns, heterogeneous impacts by health condition, and their potential offsetting effects on the utilization of downstream health services.

What happens to drug use and expenditure when cost sharing is completely removed? Evidence from a Canadian provincial public drug plan

OBJECTIVES

The role of cost-sharing for medicines is under active policy discussion, including in proposals for value-based insurance design. To inform this debate, we estimated the impact of completely removing cost-sharing on medication use and expenditure using a quasi-experimental approach.

METHODS

Fair PharmaCare, British Columbia's income-based public drug plan, includes a household out-of-pocket limit. Therefore, when one household member starts a long-term high-cost drug surpassing this maximum, cost-sharing is completely removed for other family members. We used an interrupted time series design to estimate monthly prescriptions and expenditures of other household members, 24 months before and after cost-sharing removal.

RESULTS

We studied 2191 household members newly free of cost-sharing requirements, most of whom had lower incomes. R emoving cost-sharing increased the level of drug expenditure and prescription numbers by 16 and 19%, respectively (i.e. $2659.43 (95%$1507.27-$3811.59, p < 0.001); 50.0 (95%CI 25.1-74.9, p < 0.001)) relative to prior expenditures and utilization without changing pre-existing trends. Much of this change was driven by 533 individuals initiating medication for the first time after cost-sharing removal. This initiation substantially increased average expenditure, especially for antiviral agents.

CONCLUSIONS

Completely removing cost-sharing, independent of health status, significantly increased medication use and expenditure particularly due to medicine initiation by new users. While costs may be preventing use, the appropriateness of additional use, especially among new users, is unclear.

Universal drug coverage and income-related disparities in glycaemic control

AIMS

To examine whether income-related disparities in glycaemic control decline after the age of 65 years, when publicly funded universal drug insurance is acquired in Ontario, Canada.

METHODS

We conducted a population-based cross-sectional study using linked administrative healthcare databases. Adults with diabetes, aged 40-89 years, with available HbA_1c data were included (N = 716 297). Income was based on median neighbourhood household income. Multiple linear regression was used to test for effect modification of age ≥65 years on the relationship between income and HbA_1c .

RESULTS

There was a significant inverse association between income and HbA_1c level. After adjusting for baseline factors, the effect of income on HbA_1c level was significantly greater for individuals aged <65 years (mean difference HbA_1c for lowest vs highest income group +2.5 mmol/mol, 95% CI +2.3 to +2.7 [+0.23%, 95% CI 0.21 to 0.24]) than for those aged ≥65 years (+1.2 mmol/mol, 95% CI +1.0 to +1.3 [+0.11%, 95% CI 0.10 to 0.12]; P < 0.0001 for interaction).

CONCLUSIONS

Despite universal access to healthcare, people with diabetes with lower incomes had significantly worse glycaemic control compared with their counterparts on higher incomes. However, income gradients in glycaemic control were markedly reduced after the age of 65 years, possibly as a result of access to prescription drug coverage.

Policy Recommendations for Pharmacy Benefit Managers to Stem the Escalating Costs of Prescription Drugs: A Position Paper From the American College of Physicians

Recent discussions about the increasing prices of prescription drugs have focused on pharmacy benefit managers (PBMs), third-party intermediaries for various types of employers and government purchasers who negotiate drug prices in health plans and thus play a crucial role in determining the amount millions of Americans pay for medications. In this position paper, the American College of Physicians expands on its position paper from 2016 by offering additional recommendations to improve transparency in the PBM industry and highlighting the need for reliable, timely, and relevant information on prescription drug pricing for physicians and patients.

Strategies for Delivering Value-Based Care: Do Care Management Practices Improve Hospital Performance?

EXECUTIVE SUMMARY

Value-based payment has the potential to rein in the volume incentive inherent in fee-for-service payment by holding providers accountable for the quality of patient care they deliver. Success under the new payment structure will depend on how effectively key organizational reforms are embraced by providers in the implementation of quality improvement processes for care delivery. This study examined the relationship between implementation of care management processes (CMPs, the specific tactics that enable the practice of value-based care) and hospital performance under value-based payment. Using the American Hospital Association's Survey of Care Systems and Payment and the Centers for Medicare & Medicaid Services' Hospital Compare, we estimated the relationship between hospital implementation of CMPs and performance as it relates to spending, patient satisfaction, readmission reduction, value-based purchasing, and clinical care outcomes. We found that hospitals increased implementation of CMPs from 2013 to 2014, which has led to modest changes in performance. We concluded that care coordination is associated with greater improvements in hospital performance. However, the long-term effects of resulting changes in care delivery may differ from the short-term effects. Thus, study findings underscore the importance of continued evaluation of care management practice as a strategy for optimizing delivery of high-quality, efficient patient care.

Pharmacy-based predictors of non-adherence, non-persistence and reinitiation of antihypertensive drugs among patients on oral diabetes drugs in the Netherlands

Background

Adherence to antihypertensive drugs in patients with diabetes is important. To support adherence, attention should be paid to the dynamic process of implementation, persistence and reinitiation of these drugs. We assessed non-adherence, non-persistence and reinitiation patterns for antihypertensive drugs in patients on oral diabetes drugs and identified pharmacy-based predictors of these processes.

Methods

We conducted a cohort study in patients on oral diabetes drugs who initiated antihypertensive drugs between 1995–2015, as registered in the IADB.nl pharmacy database. Non-adherence was defined as a medication possession ratio < 80% and non-persistence as a gap > 180 days. We defined reinitiation as the dispensing of an antihypertensive drug within one year following discontinuation. We provide descriptive statistics for different time periods and applied logistic and Cox regressions to assess associations with sociodemographic and drug-related factors.

Results

Of 6,669 initiators, non-adherence rates in persistent patients decreased from 11.0% in the first year to 8.5% and 7.7% in the second and third years, respectively. Non-persistence rates decreased from 18.0% in the first year to 3.7% and 2.9% in the second and third years, respectively. Of the 1,201 patients who discontinued in the first year, 22.0% reinitiated treatment within one year. Non-adherence and non-persistence rates were lower in the more recent time period. Predictors of non-adherence were secondary prevention (OR: 1.45; 95% CI: 1.10–1.93) and diuretics as initial drug class (OR: 1.37; 95% CI: 1.08–1.74). Predictors of non-persistence were female gender (HR: 1.18; 95% CI: 1.05–1.32), older age (HR: 1.33; 95% CI: 1.08–1.63) and diuretics, beta-blocking agents or calcium channel blockers as initial drug class. Longer duration of persistence was a predictor of reinitiation.

Conclusions

Adherence to antihypertensive drugs in patients on oral diabetes drugs has improved over time. The first year after initiation is the most crucial with regard to non-adherence and non-persistence, and the risk groups are different for both processes. Early non-persistence is a risk factor for not reinitiating treatment.

Cancer History, Health Insurance Coverage, and Cost-Related Medication Nonadherence and Medication Cost-Coping Strategies in the United States

OBJECTIVES

To evaluate the relationship between cancer history and cost-related medication nonadherence (CRN) as well as cost-coping strategies, by health insurance coverage.

METHODS

We used the 2013 to 2016 National Health Interview Survey to identify adults aged 18 to 64 years with (n = 3599) and without (n = 56 909) a cancer history. Cost-related changes in medication use included (1) CRN, measured as skipping, taking less, or delaying medication because of cost, and (2) cost-coping strategies, measured as requesting lower cost medication or using alternative therapies to save money. Separate multivariable logistic regressions were used to calculate the adjusted odds ratios (AORs) of CRN and cost-coping strategies associated with cancer history, stratified by insurance.

RESULTS

Cancer survivors were more likely than adults without a cancer history to report CRN (AOR 1.26; 95% confidence interval [CI] 1.10-1.43) and cost-coping strategies (AOR 1.10; 95% CI 0.99-1.19). Among the privately insured, the difference in CRN by cancer history was the greatest among those enrolled in high-deductible health plans (HDHPs) without health savings accounts (HSAs) (AOR 1.78; 95% CI 1.30-2.44). Among adults with HDHP and HSA, cancer survivors were less likely to report cost-coping strategies (AOR 0.62; 95% CI 0.42-0.90). Regardless of cancer history, CRN and cost-coping strategies were the highest for those uninsured, enrolled in HDHP without HSA, and without prescription drug coverage under their health plan (all P<.001).

CONCLUSIONS

Cancer survivors are prone to CRN and more likely to use cost-coping strategies. Expanding options for health insurance coverage, use of HSAs for those with HDHP, and enhanced prescription drug coverage may effectively address CRN.

Are the Benefits of Value-Based Insurance Design Conclusive?

Questions about the clinical significance of improvements to medication adherence resulting from value-based insurance design (VBID) policies persist in the literature. Given the lack of conclusive evidence about effectiveness, in addition to concerns about the cost of implementing VBID programs, it is perhaps not surprising that VBID is not more widely used by managed care plans. Although VBID holds promise for improving chronic medication use, additional evidence is needed if VBID is to become universally adopted. DISCLOSURES: No funding contributed to the writing of this article. The author currently receives funding from Blue-Cross Blue-Shield of Minnesota for unrelated research.

Breast Screening Utilization and Cost Sharing Among Employed Insured Women After the Affordable Care Act

OBJECTIVE

To assess changes in screening mammography cost sharing and utilization before and after the Affordable Care Act (ACA) and the revised US Preventive Services Task Force (USPSTF) guidelines. To compare mammography cost sharing between women aged 40 to 49 and those 50 to 74.

METHODS

We used patient-level analytic files between 2004 and 2014 from Clinformatics Data Mart (OptumInsight, Eden Prairie, Minnesota). We included women 40 to 74 years without a history of breast cancer or mastectomy. We conducted an interrupted time series analyses assessing cost sharing and utilization trends before and after the ACA implementation and USPSTF revised guidelines.

RESULTS

We identified 1,763,959 commercially insured women aged 40 to 74 years. Between 2004 and 2014, the proportion of women with zero cost share for screening mammography increased from 81.9% in 2004 to 98.2% in 2014, reaching 93.1% with the 2010 ACA implementation. The adjusted median cost share remained $0 over time. Initially at 36.0% in 2004, screening utilization peaked at 42.2% in 2009 with the USPSTF guidelines change, dropping to 40.0% in 2014. Comparing women aged 40 to 49, 50 to 64, and 65 to 74, the proportion exposed to cost sharing declined over time in all groups.

CONCLUSIONS

A substantial majority of commercially insured women had first-dollar coverage for mammography before the ACA. After ACA, nearly all women had access to zero cost-share mammography. The lack of an increase in mammography use post-ACA can be partially attributed to a USPSTF guideline change, the high proportion of women without cost sharing before the ACA, and the relatively low levels of cost sharing before the policy implementation.

Do interventions that address patient cost-sharing improve adherence to prescription drugs? A systematic review of recently published studies

INTRODUCTION

Poor prescription drug adherence is common, jeopardizing the benefits of treatment and increasing the costs of health care in the United States. A frequently reported barrier to adherence is patient out-of-pocket (OOP) costs. Areas Covered: This systematic review examines interventions that address patient cost-sharing to improve adherence to prescription drugs and reduce costs of care. Twenty-eight published studies were identified with 22 distinct interventions. Most papers were published in or after 2010, and nearly a third were published after 2014. Expert Opinion: Many of the interventions were associated with improved adherence compared to controls, but effects were modest and varied across drug classes. In some studies, adherence remained stable in the intervention group, but declined in the control group. Patient OOP costs generally declined following the intervention, usually as a direct result of the financial structure of the intervention, such as elimination of copayments, and costs to health plans for prescription drugs increased accordingly. For those studies that reported drug and nondrug costs, lower health plan nondrug medical spending generally compensated for increased spending on prescription drugs. With increasing health-care spending, especially for prescription drugs, efforts to improve prescription drug adherence in the United States are important. Federal policies regarding prescription drug prices may have an impact on cost-related nonadherence, but the content and timing of any policies are hard to predict. As such, employers and health plans will face greater pressure to explore innovative approaches to lowering costs and increasing access for beneficiaries. Value-based financial incentive models have the potential to be a part of this effort; research should continue to evaluate their effectiveness.

High-Deductible Insurance and Delay in Care for the Macrovascular Complications of Diabetes

BACKGROUND

Little is known about the long-term effects of high-deductible insurance on care for chronic medical conditions.

OBJECTIVE

To determine whether a transition from low-deductible to high-deductible insurance is associated with delayed medical care for macrovascular complications of diabetes.

DESIGN

Observational longitudinal comparison of matched groups.

SETTING

A large national health insurer during 2003 to 2012.

PARTICIPANTS

The intervention group comprised 33 957 persons with diabetes who were continuously enrolled in low-deductible (≤$500) insurance plans during a baseline year followed by up to 4 years in high-deductible (≥$1000) plans. The control group included 294 942 persons with diabetes who were enrolled in low-deductible plans contemporaneously with matched intervention group members.

INTERVENTION

Employer-mandated transition to a high-deductible plan.

MEASUREMENTS

The number of months it took for persons in each study group to seek care for their first major macrovascular symptom, have their first major diagnostic test for macrovascular disease, and have their first major procedure-based treatment was determined. Between-group differences in time to reach a midpoint event rate were then calculated.

RESULTS

No baseline differences were found between groups. During follow-up, the delay for the high-deductible group was 1.5 months (95% CI, 0.8 to 2.3 months) for seeking care for the first major symptom, 1.9 months (CI, 1.4 to 2.3 months) for the first diagnostic test, and 3.1 months (CI, 0.5 to 5.8 months) for the first procedure-based treatment.

LIMITATION

Health outcomes were not examined.

CONCLUSION

Among persons with diabetes, mandated enrollment in a high-deductible insurance plan was associated with delays in seeking care for the first major symptoms of macrovascular disease, the first diagnostic test, and the first procedure-based treatment.

PRIMARY FUNDING SOURCE

National Institute of Diabetes and Digestive and Kidney Diseases.

Turning teams and pathways into integrated practice units: Appearance characteristics and added value

It has been 12 years after Porter and Teisberg published their landmark manuscript on "Redefining Health Care." Apart from stressing the need for a fundamental change from fee-for-service to value or outcome-based financing and to a focus on reducing waste, they emphasized the need to work along patient pathways and in Integrated Practice Units to overcome function based and specialist group silos and promote working in multidisciplinary patient-oriented teams. Integrated Practice Units are defined as "organized around the patient and providing the full cycle of care for a medical condition, including patient education, engagement, and follow-up and encompass inpatient, outpatient and rehabilitative care as well as supporting services." Although relatively few papers are published with empirical evidence on Integrated Practice Units development, some providers have impressively developed pathways and integrated care toward alignment with Integrated Practice Units criteria. From the field, we learn that possible advantages lay in improving patient centeredness, breaking through professional boundaries, and reducing waste in unnecessary duplications. A firm body of evidence on the added value of turning pathways into Integrated Practice Units is hard to find and this leaves room for much variation. Although intuitively attractive, this development requires staff efforts and costs and therefore cost-effectiveness and budget impact studies are much needed. Randomized controlled trials may be difficult to realize in organizational research, it is long known that turning to alternative designs such as larger case study series and before-after designs can be helpful. Thus, it can become clear what added value is achievable and how to reach that.

Effect of a Remotely Delivered Tailored Multicomponent Approach to Enhance Medication Taking for Patients With Hyperlipidemia, Hypertension, and Diabetes: The STIC2IT Cluster Randomized Clinical Trial

IMPORTANCE

Approximately half of patients with chronic conditions are nonadherent to prescribed medications, and interventions have been only modestly effective.

OBJECTIVE

To evaluate the effect of a remotely delivered multicomponent behaviorally tailored intervention on adherence to medications for hyperlipidemia, hypertension, and diabetes.

DESIGN, SETTING, AND PARTICIPANTS

Two-arm pragmatic cluster randomized controlled trial at a multispecialty group practice including participants 18 to 85 years old with suboptimal hyperlipidemia, hypertension, or diabetes disease control, and who were nonadherent to prescribed medications for these conditions.

INTERVENTIONS

Usual care or a multicomponent intervention using telephone-delivered behavioral interviewing by trained clinical pharmacists, text messaging, pillboxes, and mailed progress reports. The intervention was tailored to individual barriers and level of activation.

MAIN OUTCOMES AND MEASURES

The primary outcome was medication adherence from pharmacy claims data. Secondary outcomes were disease control based on achieved levels of low-density lipoprotein cholesterol, systolic blood pressure, and hemoglobin A1c from electronic health records, and health care resource use from claims data. Outcomes were evaluated using intention-to-treat principles and multiple imputation for missing values.

RESULTS

Fourteen practice sites with 4078 participants had a mean (SD) age of 59.8 (11.6) years; 45.1% were female. Seven sites were each randomized to intervention or usual care. The intervention resulted in a 4.7% (95% CI, 3.0%-6.4%) improvement in adherence vs usual care but no difference in the odds of achieving good disease control for at least 1 (odds ratio [OR], 1.10; 95% CI, 0.94-1.28) or all eligible conditions (OR, 1.05; 95% CI, 0.91-1.22), hospitalization (OR, 1.02; 95% CI, 0.78-1.34), or having a physician office visit (OR, 1.11; 95% CI, 0.91-1.36). However, intervention participants were significantly less likely to have an emergency department visit (OR, 0.62; 95% CI, 0.45-0.85). In as-treated analyses, the intervention was associated with a 10.4% (95% CI, 8.2%-12.5%) increase in adherence, a significant increase in patients achieving disease control for at least 1 eligible condition (OR, 1.24; 95% CI, 1.03-1.50), and nonsignificantly improved disease control for all eligible conditions (OR, 1.18; 95% CI, 0.99-1.41).

CONCLUSIONS AND RELEVANCE

A remotely delivered multicomponent behaviorally tailored intervention resulted in a statistically significant increase in medication adherence but did not change clinical outcomes. Future work should focus on identifying which groups derive the most clinical benefit from adherence improvement efforts.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02512276.

Impact of consumer-directed health plans on low-value healthcare

OBJECTIVES

To assess the impact of consumer-directed health plan (CDHP) enrollment on low-value healthcare spending.

STUDY DESIGN

We performed a quasi-experimental analysis using insurance claims data from 376,091 patients aged 18 to 63 years continuously enrolled in a plan from a large national commercial insurer from 2011 to 2013. We measured spending on 26 low-value healthcare services that offer unclear or no clinical benefit.

METHODS

Employing a difference-in-differences approach, we compared the change in spending on low-value services for patients switching from a traditional health plan to a CDHP with the change in spending on low-value services for matched patients remaining in a traditional plan.

RESULTS

Switching to a CDHP was associated with a $231.60 reduction in annual outpatient spending (95% CI, -$341.65 to -$121.53); however, no significant reductions were observed in annual spending on the 26 low-value services (--$3.64; 95% CI, -$9.60 to $2.31) or on these low-value services relative to overall outpatient spending (-$7.86 per $10,000 in outpatient spending; 95% CI, -$18.43 to $2.72). Similarly, a small reduction was noted for low-value spending on imaging (-$1.76; 95% CI, -$3.39 to -$0.14), but not relative to overall imaging spending, and no significant reductions were noted in low-value laboratory spending.

CONCLUSIONS

CDHPs in their current form may represent too blunt an instrument to specifically curtail low-value healthcare spending.

Understanding the patient experience of cost-related non-adherence to prescription medications through typology development and application

Many patients report skipping doses, splitting pills, or not filling prescriptions due to out-of-pocket costs-a phenomenon known as cost-related non-adherence (CRNA). This study investigated CRNA from the patient's perspective, and, to our knowledge, is the first study to undertake a qualitative investigation of CRNA specifically. We report the results from 35 semi-structured interviews conducted in 2014-15 with adults in four Canadian cities across two provinces. We used framework analysis to develop a CRNA typology to characterize major factors in patients' CRNA decisions. Our typology identifies four major components: (1) the insurance reason driving the drug cost, (2) the individual's overall financial flexibility, (3) the burden of drug cost on the individual's budget, and (4) the importance of the drug from the individual's perspective. The first two components set the context for CRNA and the final two components are the drivers for the CRNA decision. We also found four major patterns in CRNA experiences: (1) CRNA in individuals with low financial flexibility occurred for all levels of drug importance and all but the lowest level of cost burden; (2) CRNA for high importance drugs only occurred when the drug cost had a high burden on an individual's budget; (3) CRNA in individuals with more financial flexibility primarily occurred in drugs with medium importance but high or very high cost burdens; and (4) CRNA for low importance drugs occurred at almost all levels of drug cost burden. Our study furthers the understanding of how numerous factors such as income, insurance, and individual preferences combine and interact to influence CRNA and suggests that policy interventions must be multi-faceted or encourage significant insurance redesign to reduce CRNA.

Impact of a Value-based Formulary on Medication Utilization, Health Services Utilization, and Expenditures

BACKGROUND

Value-based benefit design has been suggested as an effective approach to managing the high cost of pharmaceuticals in health insurance markets. Premera Blue Cross, a large regional health plan, implemented a value-based formulary (VBF) for pharmaceuticals in 2010 that explicitly used cost-effectiveness analysis (CEA) to inform medication copayments.

OBJECTIVE OF THE STUDY

The objective of the study was to determine the impact of the VBF.

DESIGN

Interrupted time series of employer-sponsored plans from 2006 to 2013.

SUBJECTS

Intervention group: 5235 beneficiaries exposed to the VBF.

CONTROL GROUP

11,171 beneficiaries in plans without any changes in pharmacy benefits.

INTERVENTION

The VBF-assigned medications with lower value (estimated by CEA) to higher copayment tiers and assigned medications with higher value to lower copayment tiers.

MEASURES

Primary outcome was medication expenditures from member, health plan, and member plus health plan perspectives. Secondary outcomes were medication utilization, emergency department visits, hospitalizations, office visits, and nonmedication expenditures.

RESULTS

In the intervention group after VBF implementation, member medication expenditures increased by $2 per member per month (PMPM) [95% confidence interval (CI), $1-$3] or 9%, whereas health plan medication expenditures decreased by $10 PMPM (CI, $18-$2) or 16%, resulting in a net decrease of $8 PMPM (CI, $15-$2) or 10%, which translates to a net savings of $1.1 million. Utilization of medications moved into lower copayment tiers increased by 1.95 days' supply (CI, 1.29-2.62) or 17%. Total medication utilization, health services utilization, and nonmedication expenditures did not change.

CONCLUSIONS

Cost-sharing informed by CEA reduced overall medication expenditures without negatively impacting medication utilization, health services utilization, or nonmedication expenditures.

Impact of a Combined Value-Based Insurance Design and Medication Therapy Management Program on Diabetes Medication Adherence

BACKGROUND

Value-based insurance design (VBID) waives or reduces prescription copayments in order to decrease member cost barriers to refilling medications. Medication therapy management (MTM) is a member clinical intervention designed to reinforce members' knowledge of their medications, which addresses barriers to medication adherence. Both methods have been shown to increase adherence in members, particularly when used in combination. To date, studies of such combined programs have often been completed within integrated health systems but have rarely included control populations.

OBJECTIVE

To determine the effect of a combined VBID and MTM program on key medication adherence metrics among diabetic members of a large employer group in the Midwest.

METHODS

A retrospective pre/post longitudinal analysis of pharmacy claims data was performed for 77 participants in a combined VBID/MTM program and 77 eligible nonparticipants, matched by the baseline adherence metrics of proportion of days covered (PDC) and number of days without therapy, also known as gaps in therapy (GIT). Oral antidiabetic medication adherence and cost-related outcomes for all pharmacy claims were evaluated within and between groups over a 6-month period. Post hoc analyses were performed to investigate the effect of the intervention by gender and among a less adherent subpopulation of participants with a PDC of < 100% at baseline.

RESULTS

Introduction of the intervention resulted in a nonsignificant increase in PDC from 92.9% to 95.4%, in contrast to a nonsignificant decrease from 92.8% to 91.7% in the comparison group. GIT underwent a nonsignificant decrease of 2.83 days during intervention, while nonsignificantly increasing 2.82 days in the comparators. Pharmacy claims costs paid by the plan per member per 6-month period significantly increased in the intervention group from $1,991.23 to $3,092.74, compared with a nonsignificant increase from $1,402.21 to $1,645.68 in the comparison group. Among the less-adherent subpopulation, PDC increased significantly after intervention from 84.7% to 93.1% compared with a nonsignificant increase from 84.6% to 89.0% among nonparticipants. A significant 10.69-day decrease in GIT was also observed among nonadherent participants compared with a nonsignificant 3.59-day decrease among nonparticipants. Female participants experienced a significant PDC increase from 91.5% to 96.8% and a GIT decrease of 7.32 days, while male participants did not change significantly.

CONCLUSIONS

While statistically significant improvements to adherence were not observed among this population of members who were highly adherent at baseline, improvement trends and subgroup analyses demonstrated that the combined VBD/MTM program may have the potential to influence member behavior in employer groups. Larger, longer-term studies are needed to confirm this potential. Additional benefit may be realized by targeting members with lower adherence metrics at baseline and examining potential cost savings associated with medical outcomes.

DISCLOSURES

Funding for this project was provided by Navitus Health Solutions. Peaslee, Wickizer, and Olson are employed by Navitus Health Solutions. Peaslee is a clinical staff pharmacist working in Formulary Services and a former PGY-1 Managed Care Clinical Pharmacy Resident at this location. Wickizer is the Associate Manager of Clinical Programs and Residency Programs. Olson is the Director of Clinical Programs and Product Development. Topp is the Patricia A. Chin Nursing Research Endowed Professor at the Hahn School of Nursing and Health Science at the University of San Diego specializing in statistics. Topp received consulting fees from Navitus Health Solutions for work on this project. Study concept and design were contributed by Peaslee, Wickizer, and Olson, with assistance from Topp. Peaslee took the lead in data collection, with assistance from Wickizer, and data interpretation was performed by Peaslee, Topp, Wickizer, and Olson. The manuscript was written primarily by Peaslee, with assistance from the other authors, and revised by Topp, Wickizer, and Olson, assisted by Peaslee.

Chronic Health Outcomes and Prescription Drug Copayments in Medicaid

BACKGROUND

Prescription drug copayments and cost-sharing have been linked to reductions in prescription drug use and expenditures. However, little is known about their effect on specific health outcomes.

OBJECTIVE

To evaluate the association between prescription drug copayments and uncontrolled hypertension, uncontrolled hypercholesterolemia, and prescription drug utilization among Medicaid beneficiaries with these conditions.

SUBJECTS

Select adults aged 20-64 from NHANES 1999-2012 in 18 states.

MEASURES

Uncontrolled hypertension, uncontrolled hypercholesterolemia, and taking medication for each of these conditions.

RESEARCH DESIGN

A differencing regression model was used to evaluate health outcomes among Medicaid beneficiaries in 4 states that introduced copayments during the study period, relative to 2 comparison groups-Medicaid beneficiaries in 14 states unaffected by shifts in copayment policy, and a within-state counterfactual group of low-income adults not on Medicaid, while controlling for individual demographic factors and unobserved state-level characteristics.

RESULTS

Although uncontrolled hypertension and hypercholesterolemia declined among all low-income persons during the study period, the trend was less pronounced in Medicaid beneficiaries affected by copayments. After netting out concurrent trends in health outcomes of low-income persons unaffected by Medicaid copayment changes, we estimated that introduction of drug copayments in Medicaid was associated with an average rise in uncontrolled hypertension and uncontrolled hypercholesterolemia of 7.7 and 13.2 percentage points, respectively, and with reduced drug utilization for hypercholesterolemia.

CONCLUSIONS

As Medicaid programs change in the years following the Affordable Care Act, prescription drug copayments may play a role as a lever for controlling hypertension and hypercholesterolemia at the population level.

Value-based Insurance Design

The increasing awareness of the scarcity of health care resources is forcing the health care industry to improve quality while lowering the cost. One method by which employers and insurance companies are attempting to do this is with value-based insurance design. In these plans, patients pay a lower amount for certain services that are considered high value and a higher amount for services that are considered low value.

The association between adherence to cardiovascular medications and healthcare utilization

BACKGROUND

Poor adherence to medications for cardiovascular disease (CVD) is associated with adverse health outcomes, but little is known about its association with healthcare utilization (HCU).

OBJECTIVE

To examine whether adherence is associated with a long-term decrease in HCU.

METHODS

This is a retrospective cohort study of 1582 patients with CVD who enrolled in Maccabi Healthcare Services in Israel, initiating CVD medication therapy in 2006. Adherence was assessed by the proportion of days covered (PDC) with medications. Patients were defined as: non-adherent (PDC <0.4), partially adherent (0.4 ≤ PDC < 0.8), and fully adherent (PDC ≥0.8). HCU was estimated for 4 years following treatment initiation. Multivariable GEE models were used to analyze predictors of HCU. Model I included total adherence during the entire follow-up period as well as the interaction between this measure and the follow-up year. Model II included previous and current year's adherence as well as previous year's HCU cost. Both models were adjusted for potential confounders including: patient's age, gender, socioeconomic status, ownership of voluntary supplementary health insurance, and comorbidities.

RESULTS

The median age of patients was 63 (69 % males). Fifty-four percent of patients (n = 860) were defined as adherent, 24 % as partially adherent and 22 % as non-adherent. Model I: the annual HCU costs of adherent patients decreased by 10 % following treatment initiation [rate ratio (RR) = 0.90, 95 % confidence interval (CI) 0.86-0.94, P < 0.001]. This decrease stemmed predominantly from reduction in hospitalization costs. No significant changes in annual costs following treatment initiation were observed among partially adherent (RR = 1.00, 95 % CI 0.90-1.10, P = 0.935) and non-adherent (RR = 0.98, 95 % CI 0.87-1.10, P = 0.681) patients. Model II: no temporal association was found between adherence and HCU.

CONCLUSIONS

Adherence to CVD medications is relatively low. Adherence is associated with long-term decrease in healthcare expenditure. Exploring reasons for the high non-adherence and ways to improve adherence may optimize utilization of health systems' scarce resources.

Impact of Out-of-Pocket Expenditure on Physical Therapy Utilization for Nonspecific Low Back Pain: Secondary Analysis of the Medical Expenditure Panel Survey Data

BACKGROUND

Physical therapy decreases low back pain, improves function, and may lead to decreased use of medical services. However, factors predicting physical therapy utilization for patients with low back pain are not well understood.

OBJECTIVES

The purpose of this study was to identify the impact of out-of-pocket expenditure on physical therapy utilization for US adults with nonspecific low back pain.

DESIGN

This study was a secondary analysis of retrospective Medical Expenditure Panel Survey data.

METHODS

The participants were US adults with nonspecific low back pain. The outcome variable was the number of visits per episode of care. The research variable was out-of-pocket expenditure. Covariate variables were Medical Outcomes Study 12-Item Short-Form Health Survey (SF-12) component scores. Descriptive statistics and multiple linear regression analyses were performed.

RESULTS

Three hundred fourteen adults met the inclusion criteria and submitted SF-12 scores, representing nearly 4 million adults. Out-of-pocket expenditure, physical component score, and the age-insurance category "18-64 years with public coverage only for all of the year or uninsured all of the year" negatively predicted visits per episode of care in the final regression model.

LIMITATIONS

Limitations of the study included use of a nonexperimental design, lack of information about symptom severity and content of physical therapy, and SF-12 scores were not taken coincidental with the episode of care.

CONCLUSIONS

Out-of-pocket expenditure negatively predicts physical therapy utilization. More research is needed to identify all factors influencing physical therapy utilization so that effective health policies may be developed.