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The American Journal of Managed Care February 2020
Care Coordination for Veterans With COPD: A Positive Deviance Study
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Preventive Drug Lists as Tools for Managing Asthma Medication Costs
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Preventive Drug Lists as Tools for Managing Asthma Medication Costs

Melissa B. Gilkey, PhD; Lauren A. Cripps, MA; Rachel S. Gruver, MPH; Deidre V. Washington, PhD; and Alison A. Galbraith, MD, MPH
Findings of this qualitative interview study suggest promise, but also challenges, with regard to using preventive drug lists to help families manage asthma medication costs.
ABSTRACT

Objectives: Preventive drug lists (PDLs) are a value-based insurance design intended to help high-deductible health plan (HDHP) members by covering preventive medications at lower or no cost before deductibles are met. Because little is known about members’ experiences using this new tool, we sought to evaluate benefits and challenges of using PDLs to manage asthma costs.

Study Design: Qualitative interview study.

Methods: In 2018, we conducted telephone interviews with US adults (n = 22) who (1) were in HDHPs with PDLs and (2) had asthma and/or a child with asthma. We analyzed data using thematic content analysis.

Results: Some members reported that PDLs provided financial benefit and facilitated adherence to preventive medications. Others experienced barriers to using PDLs. Notably, some PDLs did not include members’ asthma medications or provided only modest cost coverage due to restrictions in underlying formulary structures. Members who were aware of having a PDL sometimes worked with their providers to switch to listed medications. However, many members were not aware of having a PDL. Finally, because PDLs did not cover nonmedication costs, some members still struggled to afford asthma care.

Conclusions: PDLs are a promising tool for helping families in HDHPs manage their medication costs and, in turn, their asthma. However, given current limitations in coverage, members must be aware of the benefit to seek out listed medications, and they may still struggle with the remaining cost sharing. Attention to implementation, including member outreach and education, is likely needed to realize the full potential of PDLs.

Am J Manag Care. 2020;26(2):75-79. https://doi.org/10.37765/ajmc.2020.42396
Takeaway Points

Preventive drug lists (PDLs) are a value-based insurance design meant to supplement high-deductible health plans (HDHPs) so that members receive selected preventive medications at lower or no cost before meeting their deductibles. We interviewed HDHP members affected by asthma to understand their experience using PDLs.
  • Some members perceived PDLs as providing financial benefit and facilitating medication adherence.
  • Others experienced challenges because their PDLs provided low/no coverage for asthma medications.
  • Many members were not aware of their PDL, which was a barrier to switching to listed medications.
Attention to implementation, including member education, is likely needed to realize the potential of PDLs.
Families in the United States affected by asthma have experienced a dramatic rise in the costs of medications in recent years. One reason for increasing costs is that asthma medications have become more expensive as manufacturers have replaced affordable generics with higher-cost name-brand drugs, including biologics. This shift has helped push average asthma medication costs to more than $1800 per person per year.1 At the same time, families are increasingly exposed to medication costs due to the proliferation of high-deductible health plans (HDHPs) that require them to cover costs until meeting deductibles of $2700 or more per family2-4; HDHPs that are eligible for health savings accounts (HSAs) have traditionally required members to pay the full cost of medications before reaching the deductible. This cost sharing combines with higher medication costs to increase families’ risk of out-of-pocket spending, which is associated with lower medication adherence and higher rates of asthma-related hospitalization.5-8 This convergence of market forces makes asthma a particularly salient test case for investigating the role of insurance design on health.

Preventive drug lists (PDLs) are a type of value-based insurance design that have been proposed as a tool for addressing the barriers to preventive care that attend HDHPs.9-11 PDLs are meant to supplement HSA-eligible HDHP coverage so that members receive selected preventive medications for chronic conditions at lower or no cost before meeting their deductibles, broadening the interpretation of Internal Revenue Service (IRS) regulations governing HSAs that permit preventive services to be exempt from the deductible in qualifying HDHPs. In this way, PDLs are designed to reduce the financial burden of preventive medications with the goal of promoting adherence, improving health, and reducing the need for costly acute care. Based on this logic, insurers across the United States have begun to adopt PDLs,12,13 although IRS authorization to include medications for chronic conditions under the category of preventive care has not been legally explicit until recently.14,15

Research to evaluate the effectiveness of value-based insurance designs, such as PDLs, is still in its early stages. The available evidence suggests that enhanced coverage for preventive medications can increase adherence across a range of health conditions, including asthma, without substantially increasing overall healthcare costs.16-21 However, improvements are typically modest, and little is known about members’ experiences using PDLs and other value-based insurance designs.16 It may be that members are unaware of opportunities to lower cost sharing or that these designs are difficult to use. Understanding barriers to PDL use could inform efforts to improve these designs so as to maximize their impact on adherence and health.

Therefore, we conducted a qualitative interview study to explore PDLs from the perspective of families affected by asthma. Asthma is an exemplar chronic condition for evaluating PDLs, as it is a common chronic condition with costly preventive medications for which adherence improves outcomes. Our objectives were to understand the extent to which PDLs help families manage asthma care costs and adhere to their preventive care regimens, as well as to identify barriers to and facilitators of PDL use. By providing novel data from HDHP members affected by asthma, this study seeks to inform the implementation of an increasingly common value-based insurance design.

METHODS

Participants

In 2017-2018, we conducted semistructured interviews about experiences related to asthma care costs with commercially insured adults. Eligible participants (1) were aged between 18 and 64 years, (2) had been continuously enrolled for at least 12 months in an HSA-eligible HDHP with a PDL (which in 2017 entailed an annual deductible of at least $1300/individual or $2600/family22), and (3) had received a diagnosis of asthma and/or were the parent of a child aged 4 to 17 years with asthma.

We recruited participants from 2 sources. First, we used claims data from Harvard Pilgrim Health Care to identify members who were likely affected by asthma. Harvard Pilgrim is a large, not-for-profit insurer covering more than 1 million members living primarily in New England. Members were flagged if they or their children had at least 1 inpatient, emergency department (ED), or outpatient claim in the prior 2 years attributed to asthma. We invited identified members to participate in the study by mail and phone, and we verified plan type with enrollment records. At the time of the study, Harvard Pilgrim’s PDL included all asthma controller and rescue medications that were on the plan’s formulary, which included some but not all asthma medications within a class; listed medications were exempt from the deductible but required a co-payment or coinsurance that was graduated according to formulary tier such that lower-tier medications had the smallest co-pay.

Second, to increase the diversity of our sample, we recruited participants in partnership with the Asthma and Allergy Foundation of America (AAFA), a national, not-for-profit patient organization. We invited participation via posts to AAFA’s Asthma Online Community, email listserv, newsletters, and flyers. We confirmed participants’ eligibility prior to interviews using a standardized screening form. We determined our sample size by thematic saturation.23


 
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