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Using Clinically Nuanced Cost Sharing to Enhance Consumer Access to Specialty Medications | Page 2

Published Online: June 27, 2014
Jason Buxbaum, MHSA; Jonas de Souza, MD; and A. Mark Fendrick, MD
Another approach to incorporating V-BID in cost sharing for specialty pharmaceuticals could entail selectively reducing cost sharing for specialty medications if the patient does not respond as desired to another medication. This is also referred to as “reward the good soldier” or “step-edit with co-payment relief.”8 For example, suppose that a payer wished to encourage the use of methotrexate as a first-line treatment for rheumatoid arthritis, given reasonable levels of effectiveness in certain patients. However, not all patients will respond adequately to therapy with only this medication. A “reward the good soldier” V-BID benefit structure would offer relief from higher cost sharing for specialty agents after failure of a lower-cost initial regimen.

4. Use Cost Sharing to Encourage Patients to Select High-Performing Providers and Settings for Care

The provider of, or setting for, any given service often serves as an important indicator of value. Accordingly, payers and purchasers can encourage consumers to select high-value settings and providers through differentiated cost sharing for specialty medications and/or provider visits. Consistent use of evidence-based clinical pathways, engagement of patients in key decisions, achievement of key condition-specific quality goals, avoidance of costly services that do not affect treatment decisions, designation as a “center of excellence,” and participation in alternative payment arrangements are examples of characteristics that payers can use to identify high-performing providers.

For clinical conditions commonly managed with specialty medications, V-BID principles can help improve quality, reduce waste, foster consumer engagement, and mitigate legitimate concerns that one-size-fits-all cost sharing may lead individuals to forgo high-value care. The ultimate test of healthcare transformation will be the extent to which it improves health and addresses rising costs. In conjunction with provider-oriented payment reform, tools like V-BID that change the focus from how much we spend to how well can help achieve these goals.

Author Affiliations: University of Michigan Center for Value-Based Insurance Design, Ann Arbor, MI (JB, AMF); Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor, MI (JB, AMF); Section of Hematology/Oncology, University of Chicago Medical Center, Chicago, IL (JD); Division of General Internal Medicine, University of Michigan School of Medicine, Ann Arbor, MI (AMF).

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Address correspondence to: A. Mark Fendrick, MD, University of Michigan Medical Center–Division of General Medicine, 300 N Ingalls Bldg, Rm 7E06, Ann Arbor, MI 48109. E-mail: amfen@umich.edu.
1. Express Scripts drug trend report. Express Scripts website. http://lab .express-scripts.com/insights/industry-updates/~/media/07e71c2358f 244678d1812c80e273014.ashx. Published 2013. Accessed June 11, 2014.

2. Specialty drug trend across the pharmacy and medical benefit. Artemetrx website. http://www.artemetrx.com/docs/ARTEMETRX_ Specialty_Trend_Rpt.pdf. Published 2013. Accessed June 11, 2014.

3. Employer health benefits 2013 annual survey. Kaiser Family Foundation website. http://kaiserfamilyfoundation.files.wordpress .com/2013/08/8465-employer-health-benefits-20131.pdf. Accessed June 11, 2014.

4. Zalasek M, Greenbaum JS, Cohen JT, et al. The value of specialty pharmaceuticals—a systematic review. Am J Manag Care. 2014;20(6): 459-470.

5. Fendrick AM, Buxbaum J, Westrich K. Supporting consumer access to specialty medications through value-based insurance design. University of Michigan School of Public Health, Center for Value-Based Insurance Design website. http://www.sph.umich.edu/vbidcenter/ publications/pdfs/2014-vbid-specialty-medications-npc-final.pdf. Accessed June 11, 2014.

6. Lee JL, Maciejewski ML, Raju SS, Shrank WH, Choudhry NK. Valuebased insurance design: quality improvement but no cost savings. Health Aff. 2013;32(7):1251-1257.

7. Choudhry NK, Fischer MA, Smith BF, et al. Five features of valuebased insurance design plans were associated with higher rates of medication adherence. Health Aff. 2014;33(3):493-501.

8. Gibson TB, Fendrick AM, Gatwood J, Chernew ME. Gaps in treatment, treatment resumption and cost-sharing. Am J Pharm Benefits. 2012:4(6):e159-e165.
Issue: June 2014
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