VBID Strategies to Encourage Drug Adherence Working, Review Finds

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An updated review of value-based insurance design (VBID) as a strategy for increasing consumer adherence to prescription medications found moderate-quality evidence that such strategies are useful for increasing the use of high-value drug classes while lowering cost sharing.

An updated review of value-based insurance design (VBID) as a strategy for increasing consumer adherence to prescription medications found moderate-quality evidence that such strategies are useful for increasing the use of high-value drug classes while lowering cost sharing.

The study was published in the July issue of Health Affairs.

The review found limited evidence to suggest that clinical outcomes and quality improved. In addition, there was no effect on total healthcare spending, which suggests that the incremental drug spending was offset by decreases in spending for other healthcare services.

The authors—including A. Mark Fendrick, MD, co-director of the University of Michigan Center for Value-Based Insurance Design and co-editor-in-chief of The American Journal of Managed Care®—included 21 unique studies in their analysis, after conducting a literature review search in online databases. The studies, all done in the last 10 years, were held to a strict standard for evidence review called the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

“Enhanced access to high-value drugs that did not lead to an increase in total spending is a win/win for both insurers and patients,” Fendrick said in a statement. “If total costs are equal, using more medicines that prevent costly hospitalizations is clearly preferable to having people being admitted to a hospital.”

The studies looked at the impact of VBID-style co-pays and coinsurance, in which patients pay less or nothing for certain drugs that are known to provide high value for patients with certain chronic conditions, in this case diabetes, high blood pressure, high cholesterol, and asthma.


VBID has increasingly been implemented by private and public payers and has inspired demonstration programs in Medicare Advantage and TRICARE.

The researchers looked at the impact of low out-of-pocket costs for patients on their medication adherence, measured by how much of the medication the patient had obtained (known as the medication possession ratio) compared with the duration of the prescription (also known as the proportion of days covered [PDC]).

They also looked at what the studies found about the healthcare spending, use of healthcare services, and clinical outcomes and quality for patients in VBID plans compared with non-VBID plans.

Nearly all of the studies that examined diabetes drug use showed a significant increase in drug adherence with a VBID design, with the exception of 1 study that showed no difference in PDC at 3 years, although there was significant increase at an earlier follow-up point. Another study had equivocal results. In 2 studies, the increase came in conjunction with coaching or a disease management program.

Nearly all of the studies of VBID designs for blood pressure medications, including angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and beta blockers, showed an improvement in adherence. One study showed no significant difference in adherence.

All the studies of statins to lower cholesterol levels showed improvement in adherence.

Two of the 5 asthma studies showed an increase in adherence, whereas the other 3 studies showed no significant difference.

In addition, 9 of the studies looked at healthcare spending for patients in VBID plans compared with those in conventional plans. Most of the studies showed that the insurer experienced increased prescription drug spending, and 3 of the studies showed that patients’ out-of-pocket costs dropped significantly.

When total costs were reported, 2 studies showed decreases in spending and 7 showed no difference, suggesting that increased spending on drugs was offset by decreased spending elsewhere.

Looking at the utilization of healthcare services, 6 studies assessed the outcome of healthcare service use; of those, 2 showed significant decreases in the number of emergency department visits and hospitalizations with VBID.

There were some limitations with the review, the authors said. There is a paucity of data on patient-centered outcomes such as healthcare quality and clinical outcomes. Second, there is a lack of published literature on VBID programs that discourage the use of low-value therapies by increasing cost sharing.

The authors could not find any published controlled studies that evaluated the effect of increasing co-payments for low-value services. Increasing cost sharing for low-value services offsets the spending incurred in lowering cost sharing for high-value services. As a result, there is likely an underestimation of the overall financial offsets incurred by VBID.

The authors said that future research should focus on evaluating patient-centered outcomes and health system quality metrics in the context of VBID, as well as its effect on preventable hospitalizations and emergency department visits.

The paper’s other authors include Rajender Agarwal, MBA, now director of the Center for Health Reform in Texas, who conducted the review of evidence while earning his MBA at Indiana University, and the center’s associate director, Ashutosh Gupta.


Agarwal R, Gupta A, Fendrick AM. Value-based insurance design improves medication adherence without an increase in total health care spending. Health Aff (Millwood). 2018;37(7):1057-1064. doi: 10.1377/hlthaff.2017.1633.