Effects of increased patient cost sharing on socioeconomic disparities in health care.

BACKGROUND: Increasing patient cost sharing is a commonly employed mechanism to contain health care expenditures. OBJECTIVE: To explore whether the impact of increases in prescription drug copayments differs between high- and low-income areas. DESIGN: Using a database of 6 million enrollees with employer-sponsored health insurance, econometric models were used to examine the relationship between changes in drug copayments and adherence with medications for the treatment of diabetes mellitus (DM) and congestive heart failure (CHF). SUBJECTS: Individuals 18 years of age and older meeting prespecified diagnostic criteria for DM or CHF were included. MEASUREMENTS: Median household income in the patient's ZIP code of residence from the 2000 Census was used as the measure of income. Adherence was measured by medication possession ratio: the proportion of days on which a patient had a medication available. RESULTS: Patients in low-income areas were more sensitive to copayment changes than patients in high- or middle-income areas. The relationship between income and price sensitivity was particularly strong for CHF patients. Above the lowest income category, price responsiveness to copayment rates was not consistently related to income. CONCLUSIONS: The relationship between medication adherence and income may account for a portion of the observed disparities in health across socioeconomic groups. Rising copayments may worsen disparities and adversely affect health, particularly among patients living in low-income areas.

The effects of copayments on medication adherence during the first two years of prescription drug treatment.

OBJECTIVE: The aim of this study was to examine effects of initial prescription copayment size and observed increase on adherence by analyzing data from a managed care database. METHODS: Medical-pharmacy claims data were abstracted from the Integrated Health Care Information Services (IHCIS) National Managed Care Benchmark database for primary employer-sponsored subscribers. Incident fills and refills for the 10 most common medication groups between 2001 and 2003 were predicted by size and observed increase in copayment with the use of survival analysis. RESULTS: High copayments and observed copayment increases were associated with termination of medication use. Whereas effects of copayment level were limited to the first few fills, effects of observed increases in copayments were persistent. CONCLUSIONS: The strategy of increasing initially low copayments after the patient has made enough fills to become insensitive to copayment level is contraindicated by observed increases in copayment, predicting termination. However, other financial incentives might nonetheless help reduce early termination of medication use.

Antidepressant adherence and medical resource use among managed care patients with anxiety disorders.

OBJECTIVES: This study evaluated adherence with selective serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) among patients who newly initiated therapy for anxiety with or without comorbid depression; the study also quantified the health-related economic consequences of nonadherence. METHODS: A large managed care database was used to gather retrospective data for patients with anxiety disorders who had a prescription for an antidepressant between July 1, 2001, and December 31, 2002. The relationship between antidepressant adherence and medical resource utilization was assessed; the analysis controlled for age, gender, utilization of mental health specialty care, change in medication, whether the dosage was titrated, costs in the six months before the prescription for an antidepressant, and comorbid physical conditions. RESULTS: Of the 13,085 patients with anxiety diagnoses who met the criteria for study inclusion, 57 percent were nonadherent to antidepressant therapy at six months. Patients who received mental health specialty care were more likely than those who did not receive such care to be adherent to therapy (48.5 percent compared with 40.7 percent; p<.001). Those with dual diagnoses of anxiety and depression were more likely than those with anxiety alone to be adherent to therapy (46.8 percent compared with 40.2 percent; p<.001). Those with a coded diagnosis of posttraumatic stress disorder had the highest medical costs. Patients with anxiety and depression had significantly higher total costs than patients with anxiety alone. Adherent patients who did not have a change in medication or a titrated dosage had significantly lower medical costs than nonadherent patients; however, total costs (medical plus pharmacy) were similar. CONCLUSIONS: Nonadherence with antidepressant therapy in anxiety disorders is common, but mental health specialty care may be associated with improved adherence. Lower medical costs for adherent patients who did not have a change in medication or a titrated dosage offset the increase in pharmacy costs, resulting in total costs (medical plus pharmacy) that were similar to those of nonadherent patients.

Impact of antidepressant drug adherence on comorbid medication use and resource utilization.

BACKGROUND: Patients with depression are often nonadherent to therapy for depression and chronic comorbid conditions. METHODS: To determine whether improved antidepressant medication adherence is associated with an increased likelihood of chronic comorbid disease medication adherence and reduced medical costs, we conducted a retrospective study of patients initiating antidepressant drug therapy with evidence of dyslipidemia, coronary artery disease (CAD), or both; diabetes mellitus (DM); or CAD/dyslipidemia and DM identified from a claims database. Measures included antidepressant medication adherence, measured by medication possession ratio during 180 days without a 15-day gap before 90 days of therapy; comorbid medication adherence, measured by medication possession ratio during 1 year; and the association between improved antidepressant drug adherence and disease-specific and total medical costs. RESULTS: Of 8040 patients meeting the study criteria, those adherent to antidepressant medication were more likely to be adherent to comorbid therapy vs those nonadherent to antidepressant drug therapy (CAD/dyslipidemia: odds ratio [OR], 2.13; DM: OR, 1.82; and CAD/dyslipidemia/DM: OR, 1.45; P<.001 for all). Patients adherent to antidepressant drug therapy also had significantly lower disease-specific charges vs nonadherent patients (17% lower in CAD/dyslipidemia, P = .02; 8% lower in DM, P = .39; and 14% lower in CAD/dyslipidemia/DM, P = .38). These patients also incurred lower total medical charges (6.4% lower in CAD/dyslipidemia, P = .048; 11.8% lower in DM, P = .04; and 19.8% lower in CAD/dyslipidemia/DM, P = .03). CONCLUSIONS: Antidepressant drug adherence was associated with increased comorbid disease medication adherence and reduced total medical costs for CAD/dyslipidemia, DM, and CAD/dyslipidemia/DM. Future studies should investigate the relationship between increased adherence and costs beyond 1 year.

Effective coverage and reimbursement strategies for etanercept and infliximab in the treatment of rheumatoid arthritis.

Early and aggressive treatment of rheumatoid arthritis (RA) can provide cost savings through enhanced and sustained clinical outcomes. Antitumor necrosis factor-alpha (anti-TNF) agents, such as infliximab and etanercept, provide a superior level of clinical benefit, particularly in patients with moderate-to-severe RA. Reimbursement of these agents falls under either a pharmacy or medical benefit, depending on their route of administration. However, inconsistencies in reimbursement strategies across plans potentially restrict clinician and patient access to these safe and effective therapies. Benefits should be designed to ensure that all eligible patients have access to anti-TNF agents, with the understanding that earlier treatment of RA with safe and effective agents provides significant cost savings to future insurers through enhanced and sustained outcomes.

Evidence that value-based insurance can be effective.

Value-based insurance design reduces patient copayments to encourage the use of health care services of high clinical value. As employers face constant pressure to control health care costs, this type of coverage has received much attention as a cost-savings device. This paper's examination of one value-based insurance design program found that the program led to reduced use of nondrug health care services, offsetting the costs associated with additional use of drugs encouraged by the program. The findings suggest that value-based insurance design programs do not increase total systemwide medical spending.

Impact of decreasing copayments on medication adherence within a disease management environment.

This paper estimates the effects of a large employer's value-based insurance initiative designed to improve adherence to recommended treatment regimens. The intervention reduced copayments for five chronic medication classes in the context of a disease management (DM) program. Compared to a control employer that used the same DM program, adherence to medications in the value-based intervention increased for four of five medication classes, reducing nonadherence by 7-14 percent. The results demonstrate the potential for copayment reductions for highly valued services to increase medication adherence above the effects of existing DM programs.

Methods for evaluating patient adherence to antidepressant therapy: a real-world comparison of adherence and economic outcomes.

OBJECTIVE: The objective of this study was to differentiate between 3 measures of antidepressant adherence with regard to the number of patients deemed adherent to therapy and the association between adherence and resource utilization. DESIGN AND SETTING: The authors conducted a retrospective study of patients initiating selective serotonin reuptake inhibitor (SSRI) therapy for depression and/or anxiety between July 2001 and June 2002 in a large national managed care database. MAIN OUTCOME MEASURES: Rates of 6-month SSRI adherence were measured by 3 different metrics: length of therapy (LOT), medication possession ratio (MPR), and combined MPR/LOT. Differences in resource utilization for each adherence metric were measured for patients deemed as 1) adherent, 2) nonadherent, 3) therapy changers, and 4) dose titraters. RESULTS: There were 22,947 patients meeting study criteria. Although statistically different, 6-month adherence rates were numerically similar across all methods (LOT, 44.6%; MPR, 43.3%; and MPR/LOT, 42.9%, P < 0.001); approximately 57% of patients were nonadherent to therapy. Regardless of metric, the adherent cohort incurred the lowest yearly medical costs, followed by the nonadherent, titrate, and therapy change cohorts (P < 0.001 between adherent cohort and all other cohorts). The LOT method produced the greatest difference in yearly medical costs between adherent and nonadherent patients (Dollars 511) followed by MPR/LOT (Dollars 432) and MPR (Dollars 423). When antidepressant prescription costs were added to medical costs, patients requiring a therapy change and titrating therapy incurred higher costs than adherent patients, whereas nonadherent and adherent patients incurred similar costs. CONCLUSION: Regardless of adherence metric, approximately 43% of patients were adherent to antidepressant therapy, and adherent patients were associated with the lowest yearly medical costs.

Impact of medication adherence on hospitalization risk and healthcare cost.

OBJECTIVE: The objective of this study was to evaluate the impact of medication adherence on healthcare utilization and cost for 4 chronic conditions that are major drivers of drug spending: diabetes, hypertension, hypercholesterolemia, and congestive heart failure. RESEARCH DESIGN: The authors conducted a retrospective cohort observation of patients who were continuously enrolled in medical and prescription benefit plans from June 1997 through May 1999. Patients were identified for disease-specific analysis based on claims for outpatient, emergency room, or inpatient services during the first 12 months of the study. Using an integrated analysis of administrative claims data, medical and drug utilization were measured during the 12-month period after patient identification. Medication adherence was defined by days' supply of maintenance medications for each condition. PATIENTS: The study consisted of a population-based sample of 137,277 patients under age 65. MEASURES: Disease-related and all-cause medical costs, drug costs, and hospitalization risk were measured. Using regression analysis, these measures were modeled at varying levels of medication adherence. RESULTS: For diabetes and hypercholesterolemia, a high level of medication adherence was associated with lower disease-related medical costs. For these conditions, higher medication costs were more than offset by medical cost reductions, producing a net reduction in overall healthcare costs. For diabetes, hypercholesterolemia, and hypertension, cost offsets were observed for all-cause medical costs at high levels of medication adherence. For all 4 conditions, hospitalization rates were significantly lower for patients with high medication adherence. CONCLUSIONS: For some chronic conditions, increased drug utilization can provide a net economic return when it is driven by improved adherence with guidelines-based therapy.