Nonadherence to prescription medications is a significant factor contributing to the high clinical and economic costs of chronic disease. For example, only about 50% of patients with hypertension have the disease controlled, despite the efficacy of taking antihypertensive medication as prescribed.1 Similarly, about 50% of patients prescribed antidepressants, one of the most commonly prescribed medication classes, become nonadherent within 6 months after treatment initiation.2,3 More broadly, as many as 50% of patients do not take their prescriptions for the recommended duration and about 20% to 30% of patients do not fill their prescriptions.4
Nonadherence may be due to financial barriers or patients misperceiving the importance or value of their prescription medication. Numerous insurers and employers have turned to value-based insurance designs (VBIDs) that reduce or eliminate co-pays for relevant chronic disease medications to increase medication adherence. There is also hope that these programs will ultimately decrease total spending.
A large amount of evidence demonstrates that medication adherence increases following the reduction or complete removal of patient cost sharing for chronic disease prescriptions.5,6 However, there is limited evidence that reducing cost sharing reduces total spending.7,8 A recent literature review on VBIDs for chronic disease medications found 9 studies that examined VBID’s effect on total spending and spending on prescription medication.9 Results of 7 studies showed an increase in prescription drug spending, and just 1 study, by Kim et al, showed a reduction in total spending relative to a control group.8 Other study findings revealed no statistically significant difference in total spending. (Findings of a second study by Hirth et al evaluating Connecticut state employees’ 2011 VBID plan showed a statistically significant increase in total spending relative to employees in neighboring states.10 However, the authors did not draw strong conclusions from this secondary outcome because the control group’s spending was significantly different from the treatment group’s spending prior to the introduction of the VBID program.) Typically, these programs focus on a small set of medications or a handful of disease categories, perhaps limiting the effectiveness of the programs. Importantly, patients with chronic disease typically have multiple comorbidities and have a higher rate of mental illness relative to the US population as a whole.11 The VBID programs studied thus far have generally not supported a wide range of medications that take into account a patient’s full medical complexity.
In 2014, Blue Cross Blue Shield of Louisiana (BCBSLA) implemented a Zero Dollar Co-pay (ZDC) program, which removed the co-pay for a large set of medications related to 7 chronic diseases. This program included a larger range of drug classes relative to most other VBID programs examined in the literature. In particular, it included medications related to mental illness. Importantly, antidepressants were not included in any previously studied program. Additionally, the program reduced the co-pay for a subset of medications in each drug class rather than reducing all co-pays in a drug class, which most VBID programs in the literature have done. Overall, the ZDC program relative to many previous VBID programs included a more comprehensive set of medications and had a stronger incentive for patients to substitute different and often less expensive prescription medications. This study evaluated whether the ZDC program changed total member spending.
Setting
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Beginning in August 2014, BCBSLA rolled out its ZDC program in conjunction with its new disease management (DM) program. Although both programs served members with chronic illnesses, the ZDC program was intended for patients with chronic disease who engaged with nurse care managers (the member had to answer at least 1 call from a nurse care manager from the DM program). A member was automatically enrolled in the DM program once they were identified as having at least 1 of the following chronic diseases: asthma, chronic obstructive pulmonary disease, congestive heart failure, hypertension, diabetes, prediabetes, end-stage renal disease, and chronic kidney disease. The DM program provided members with motivational interviewing, health coaching, care plan development, long-term support, and an assessment of their health status. (The individual member health assessment was provided at the beginning of DM enrollment and included a comprehensive medical and pharmacy claim, biometric data, and personal health record review.)
Once a member was enrolled in the DM program, they were eligible for the ZDC program if they were fully insured commercial with BCBSLA’s pharmacy benefit manager. Furthermore, patients had to actively engage with a nurse care manager and take medications for at least 1 of 4 chronic conditions: asthma, diabetes, hypertension, and mental illness. BCBSLA identified a set of high-volume, low-cost medications for each relevant drug class and reduced those co-pays to $0. The majority of selected drugs were generic medications. When no generic medication was available, a branded medication was selected for inclusion in the ZDC program. Members learned about their ZDC enrollment when filling a ZDC prescription at a pharmacy. Switching from a non-ZDC to a ZDC medication requires that a provider switch a member’s prescription.
Although both the DM and ZDC programs began in August 2014, patients enrolled in the ZDC program at different times due to 2 factors: when a patient actively engaged with a nurse care manager (answered a nurse call) and when a patient or their employer changed the benefit structure to meet the ZDC program criteria. A variety of factors could have led a member to change their engagement with the DM nurse care manager or their benefit structure. In particular, ZDC enrollment could be associated with a negative health event (eg, emergency department visit, inpatient admission). If, instead, ZDC enrollment occurred due to an employer changing its benefit structure, the timing of enrollment was plausibly unrelated to member characteristics that could affect a member’s response to the ZDC program.
Source: AJMC