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Value-Based Insurance Design: Perspectives, Extending the Evidence, and Implications for the Future
John J. Mahoney, MD, MPH; Karlene Lucas, MBA; Teresa B. Gibson, PhD; Emily D. Ehrlich, MPH; Justin Gatwood, MPH; Brian J. Moore, PhD; and Kim A. Heithoff, ScD

Value-Based Insurance Design: Perspectives, Extending the Evidence, and Implications for the Future

John J. Mahoney, MD, MPH; Karlene Lucas, MBA; Teresa B. Gibson, PhD; Emily D. Ehrlich, MPH; Justin Gatwood, MPH; Brian J. Moore, PhD; and Kim A. Heithoff, ScD
The first study examined the effects of a large firm’s VBID program on medication use and savings for 4 groups of patients with diabetes.22 One group opted into a DM program, whereas the other did not, and VBID was introduced to a part of the enrollees in DM and without DM, creating 4 groups (DM/VBID, DM/No VBID, No DM/VBID, No DM/No VBID). The VBID lowered coinsurance rates to 10% for all diabetes medications from the original 3-tiered structure, in which coinsurance rates ranged from 10% to 35% (Figure 2). Primary outcome measures were medication possession ratios (MPRs)—a metric representing adherence via refilling prescriptions—and user rates. Measures for spending were total and net payments and patient outof- pocket costs. Multivariate models were estimated via generalized estimating equations.

Medication Adherence

In each of the 3 years of analysis, MPRs and the percentage of patients adherent to therapy (MPR ≥80%) were higher for those in both VBID and DM. This finding was consistent across all antidiabetic medications.22 Limited effects were observed in the group of employees with VBID and without DM: the percent adherent to oral antidiabetic medications rose in each of the first 2 years following program implementation.

Utilization

Patients in the VBID with DM combined program received a higher rate of medical services that are recommended in clinical care guidelines than those that were not offered a VBID benefit (DM/No VBID). Significant effects were also observed for those enrolled in both the VBID and DM programs (DM/VBID) compared with those who did not participate in the VBID (No DM/VBID) for glycated hemoglobin and lipid level testing, primary care physician visits, and urinalysis. These effects also increased over time.22

Spending

In each of the years following program implementation, diabetesrelated prescription drug costs rose while diabetes-related medical spending declined. The program was cost neutral; that is, total prescription drug and medical costs were no different for the VBID and DM group (DM/VBID) compared with the DM group alone (DM/No VBID) after 3 years of implementation. Overall, the combination of VBID and DM produced a diabetesrelated return on investment of $1.33 for every dollar the firm spent.

Motivation for Extending the Evidence: Exploring the Impact of a Patient’s Exposure to the True Cost of Care

Changing the prices that patients pay out of pocket for particular drug classes is a common approach of value-based prescription benefit programs. However, there is some concern that value-based programs that lower only prices that patients pay out of pocket for brand name drugs will prove to be costly, as patients may replace lower-cost generic medications with higher-cost brand medications. This is contrary to cost-sharing trends that have placed brand name medications at the highest cost-sharing levels. The average cost-sharing amount for generic medications grew 25% (from $8 to $10) between 2001 and 2012.40

Using the same study population and the same methodology as in the first study, Gibson and colleagues focused on the group with DM and explored how the change in cost-sharing in the VBID program impacted specific medications.34 This second investigation answered the following research question: For patients in the DM program, were the VBID effects in the original study consistent across brand name and generic medications?

Medication Adherence

The combined VBID and DM (DM/ VBID) program led to increased use of and adherence to oral antidiabetic medications and insulin compared with DM alone (DM/No VBID).34 Significant effects were observed for generic medication user rates and MPRs after 1 year, and the effects remained relatively stable over the 3 years of the program. Within the first year of the program, the mean MPR was 4.3 percentage points higher for those in both the VBID and DM programs versus those only in the DM program; the effect of the VBID grew slightly over time. For MPRs of brand name medications, a 1.9 percentage point program effect was observed after the first year and increased 1.4 percentage points in the each of the subsequent 2 years, achieving a final difference of 4.7 percentage points by the end of the third year. Adherence to insulin increased by 1 percentage point in the first year and 2.7 percentage points by the end of the third year.

Utilization

For the generic oral medication class, VBID effects were seen in all 3 years; user rates were 4.2 percentage points higher in the VBID group after the first year, 4.7 percentage points higher after the second year, and 5.3 percentage points higher by the end of year 3 (all P <.01).34 For brand name oral medications, user rates were 2.7 percentage points higher in the VBID group after the first year, 4.5 percentage points higher after the second year, and 6.2 percentage points higher by the end of year 3 (all P <.01).34 For insulin, significant changes were not realized until the second year of the program (year 1, P = .14; years 2 and 3, P <.01).

VBID and Disease Management: Medication Adherence and Healthcare Utilization for Cardiometabolic Comorbidities

The first 2 studies by Gibson and colleagues focused on antidiabetic medications and use of primary care services. To examine the impact of VBID on additional cardiometabolic medications, we asked 2 new questions: (1) Would the adherence effects in the original study extend to other cardiometabolic drugs that were not part of the VBID, such as statins and angiotensin-converting enzyme (ACE) inhibitors? (2) Were the effects seen with primary care services in the original study also observed for related specialty services such as cardiology, neurology, endocrinology, and nephrology?

We used the same study population and performed a descriptive analysis. With respect to the first question, use of and adherence to statins in year 3 was greater among dual VBID and DM enrollees than those only enrolled in the DM program. However, there were no significant program effects related to use of ACE inhibitors (Figure 3). With respect to the second question, there were no significant program effects related to the number of specialty office visits (Figure 4). Given the limited findings from this descriptive analysis, it is not possible to draw any conclusions related to the impact of VBID on additional cardiometabolic medications for this population; however, positive findings have been reported in similar populations when applying VBID to cardiometabolic medications.26,27

Effectiveness of VBID for Asthma Treatment

Most VBID programs to date have focused on removing financial barriers to care for a few key chronic conditions for which low adherence to medication or a disease management program can lead to poorer health outcomes and higher costs of care. This has typically included VBID programs for services related to diabetes, hypertension, and asthma.8 In 2011, it was estimated that 25.9 million Americans had asthma, including 7.1 million children; additionally, 13.2 million Americans experienced an asthma attack. The annual economic cost of asthma is more than $56 billion.41

We performed a descriptive analysis to evaluate the effects of a value-based pharmacy access program in patients with asthma; this VBID program was implemented at the same firm as the diabetes VBID program previously described. As with the diabetes program, cost-sharing was lowered to 10% for all asthma medications prescribed for employees and their dependents and the program was applied in conjunction with the DM program put in place by the firm. The structure of the asthma program was similar to the diabetes VBID program; patients opted into an asthma DM program and were offered a VBID program based on their unit or group within the employer.

We analyzed filling behavior, utilization, and spending by the employer and patient. Filling behavior was further analyzed by examining 4 categories of asthma medications: asthma controller medications (used to prevent asthma attacks); reliever medications; and brand name and generic reliever medications. There were no generic controller medications at the time of the study.

The combined VBID and DM program had 773 participants, and the DM-only program had 1346 participants. Participants filled at least 2 prescriptions for asthma medications in the baseline year (2005). Patient characteristics in the 2 groups were similar in terms of age, relationship to employee (employee, spouse, or dependent), and health status (Table 1). The VBID and DM group had a slightly longer time of enrollment, and the insurance plan type (comprehensive, exclusive provider organization, point of service plan, health maintenance organization, or preferred provider organization) and regional distribution differed between the 2 groups.

Filling Behavior

In the third year of the program, adherence to reliever medications (ie, MPR) rose 3.6 percentage points (to 19.9%) over baseline (2005) for the VBID and DM group (Figure 5; Table 2) net of trends in the DM-only group. In the third year of the program, adherence to brand name reliever medications increased 5.1 percentage points over baseline in the VBID and DM group net of trends in the DM-only group (Table 2).With respect to trends in reliever medications, user rates declined each year for those with DM only (no VBID) and also declined, but to a lesser extent, for those in the combined program.

Employer (Net) Spending

 
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