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Improved Medication Adherence May Not Save Money

By February 13, 2014Commentary

Once more we are forced to confront the reality that the hot initiatives to improve health care don’t do all they are promoted as doing.  In this case, value-based insurance design in regard to drugs, may not achieve the dual aim of improving medication adherence and lowering overall health spending.  A study from North Carolina suggests while adherence may increase, spending does not go down.  (HA Article)  Cost-sharing can be a deterrent to use of medical services.  Copayments or deductibles applicable to prescription medication have spread in recent years and may deter filling and use of the medication.  The proponents of value-based insurance design suggest that where it is clear that a particular product or service has a high value in terms of health outcomes, cost-sharing should be reduced or eliminated and that will lead to more compliance with recommended treatments as well as lower overall health spending.  Based on this theory, a number of payers have in fact reduced drug copays and in many cases, at least for generics, the reduction is to zero.  One of these payers is BCBS of North Carolina.

The study compared enrollees covered by the value-based insurance design with those who continued to have more traditional copays, some of which can be quite large on branded drugs.  The research followed these members for one year before and two years after implementation of the reduced or zero copays.  The focus was on hypertension patients, who almost always have at least one drug prescription for the condition.  The measure for adherence was the medication possession ratio, which tries to ascertain whether the patients at least had a sufficient supply to be taking the drug as indicated; but this is obviously not the best measure, since there is no way to know what patients actually did.  The outcomes were ER visits, inpatient admissions and overall health spending on the patient.  Adherence, which was fairly high, between 75% and 80%, at baseline, improved more for the value-based design enrollees than the control group, by about 1% to 4% more.  But while ER visits and admissions were somewhat lower, these differences were not significant.  And while there was a small overall spending reduction, it too was not significant, reflecting that the larger drug expenses were not offset by lower spending in other areas.  And since payers are picking up much more of the drug costs, it is not cost-neutral to them.  Whether money is saved or not, medication adherence is probably a good thing and an improvement in quality, but even that is not certain, as large-scale studies on real health outcomes where patients are more compliant either don’t exist or aren’t revealing.  And the modest pickup in adherence shown in this study isn’t likely to have a large impact on health outcomes.


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  • Ian Spector says:

    Thanks for an excellent summary of this study. Living in England I am not at all surprised by the conclusions. Having a capitated, rationed model the best outcome for the health system is that people consume very little healthcare in their youth and adult lives then when they do contract a disease they should do the honourable thing and shuffle off quickly. If you wrote that compliance with chemotherapy actually drives up the overall healthcare costs, no one would be at all surprised. I have to believe that compliance with chemo will drive up the health outcomes for most individuals if not for the overall health system.

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