Reduced Cost-sharing for Preventive Drugs Preferentially Benefits Low-income Patients With Diabetes in High Deductible Health Plans With Health Savings Accounts.
Journal
Medical care
ISSN: 1537-1948
Titre abrégé: Med Care
Pays: United States
ID NLM: 0230027
Informations de publication
Date de publication:
06 2020
06 2020
Historique:
entrez:
16
5
2020
pubmed:
16
5
2020
medline:
8
8
2020
Statut:
ppublish
Résumé
High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles. The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs. A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups. The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL. Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents. Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients. Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.
Sections du résumé
BACKGROUND
High deductible health plans linked to Health Savings Accounts (HSA-HDHPs) must include all care under the deductible except for select preventive services. Some employers and insurers have adopted Preventive Drug Lists (PDLs) that exempt specific classes of medications from deductibles.
OBJECTIVE
The objective of this study was to examine the association between shifts to PDL coverage and medication utilization among patients with diabetes in HSA-HDHPs.
RESEARCH DESIGN
A natural experiment comparing pre-post changes in monthly and annual outcomes in matched study groups.
SUBJECTS
The intervention group included 1744 commercially-insured HSA-HDHP patients with diabetes age 12-64 years switched by employers to PDL coverage; the control group included 3349 propensity-matched HSA-HDHP patients whose employers offered no PDL.
MEASURES
Outcomes were out-of-pocket (OOP) costs for medications and the number of pharmacy fills converted to 30-day equivalents.
RESULTS
Transition to the PDL was associated with a relative pre-post decrease of $612 (-35%, P<0.001) per member OOP medication expenditures; OOP reductions were higher for key classes of antidiabetic and cardiovascular medicines listed on the PDL; the policy did not affect unlisted classes. The PDL group experienced relative increases in medication use of 6.0 30-day fills per person during the year (+11.2%, P<0.001); the increase was more than twice as large for lower-income (+6.6 fills, +12.6%, P<0.001) than higher-income (+3.0 fills, +5.1%, P=0.024) patients.
CONCLUSION
Transition to a PDL which covers important classes of medication to manage diabetes and cardiovascular conditions is associated with substantial annual OOP cost savings for patients with diabetes and increased utilization of important classes of medications, especially for lower-income patients.
Identifiants
pubmed: 32412948
doi: 10.1097/MLR.0000000000001295
pii: 00005650-202006001-00004
pmc: PMC7676281
mid: NIHMS1606180
doi:
Substances chimiques
Hypoglycemic Agents
0
Types de publication
Journal Article
Research Support, N.I.H., Extramural
Langues
eng
Sous-ensembles de citation
IM
Pagination
S4-S13Subventions
Organisme : NIDDK NIH HHS
ID : P30 DK092924
Pays : United States
Organisme : NCCDPHP CDC HHS
ID : U18 DP006122
Pays : United States
Organisme : ACL HHS
ID : U18DP006122
Pays : United States
Références
Centers for Disease Control and Prevention (CDC). National Diabetes Statistics Report; 2017.
Centers for Disease Control. FastStats: Deaths and Mortality; 2019. Available at: www.cdc.gov/nchs/fastats/leading-causes-of-death.htm. Accessed June 15, 2019.
Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diabetes. 2008;26:77–82.
American Diabetes Association (ADA). Economic costs of diabetes in the U.S. in 2017. Diabetes Care. 2018;41:917–928.
Marín-Peñalver JJ, Martín-Timón I, Sevillano-Collantes C, et al. Update on the treatment of type 2 diabetes mellitus. World J Diabetes. 2016;7:354–395.
Ho PM, Bryson Chris L, Rumsfeld John S. Medication adherence: its importance in cardiovascular outcomes. Circulation. 2009;119:3028–3035.
Simard P, Presse N, Roy L, et al. Persistence and adherence to oral antidiabetics: a population-based cohort study. Acta Diabetol. 2015;52:547–556.
Herzlinger RE. Let’s put consumers in charge of health care. Harv Bus Rev. 2002;80:44–50.
Herzlinger R. Consumer-driven changes in health care in the United States. Endocr Pract. 2000;6:103–109.
Frist WH. Connected health and the rise of the patient-consumer. Health Aff (Millwood). 2014;33:191–193.
Employer Health Benefits Survey. The Henry J. Kaiser Family Foundation, Health Research and Educational Trust; 2018. Available at: www.kff.org/health-costs/report/2018-employer-health-benefits-survey/. Accessed April 15, 2019.
Internal Revenue Service. Publication 969, Health Savings Accounts and Other Tax-Favored Health Plans | Internal Revenue Service; 2018. Available at: www.irs.gov/publications/p969. Accessed June 15, 2019.
Lohr KN, Brook RH, Kamberg CJ, et al. Use of medical care in the Rand Health Insurance Experiment. Diagnosis- and service-specific analyses in a randomized controlled trial. Med Care. 1986;24(suppl):S1–S87.
Mann BS, Barnieh L, Tang K, et al. Association between drug insurance cost sharing strategies and outcomes in patients with chronic diseases: a systematic review. PLoS One. 2014;9:e89168.
Wharam JF, Zhang F, Eggleston EM, et al. Diabetes outpatient care and acute complications before and after high-deductible insurance enrollment: a Natural Experiment for Translation in Diabetes (NEXT-D) Study. JAMA Intern Med. 2017;177:358–368.
Wharam JF, Zhang F, Eggleston EM, et al. Effect of high-deductible insurance on high-acuity outcomes in diabetes: a Natural Experiment for Translation in Diabetes (NEXT-D) Study. Diabetes Care. 2018;41:940–948.
Galbraith AA, Soumerai SB, Ross-Degnan D, et al. Delayed and forgone care for families with chronic conditions in high-deductible health plans. J Gen Intern Med. 2012;27:1105–1111.
Agarwal R, Mazurenko O, Menachemi N. High-deductible health plans reduce health care cost and utilization, including use of needed preventive services. Health Aff (Millwood). 2017;36:1762–1768.
Greene J, Hibbard J, Murray JF, et al. The impact of consumer-directed health plans on prescription drug use. Health Aff (Millwood). 2008;27:1111–1119.
Fronstin P, Sepulveda M-J, Roebuck MC. Medication utilization and adherence in a health savings account-eligible plan. Am J Manag Care. 2013;19:e400–e407.
Internal Revenue Service (IRS). Health Savings Accounts and Other Tax-favored Health Plans; 2011. Available at: www.irs.gov/pub/irs-pdf/p969.pdf. Accessed June 20, 2019.
Internal Revenue Code. 26 U.S.C. 223—Health savings accounts—Content Details—USCODE-2011-title26-subtitleA-chap1-subchapB-partVII-sec223. 2018. Available at: www.govinfo.gov/app/details/USCODE-2011-title26/USCODE-2011-title26-subtitleA-chap1-subchapB-partVII-sec223. Accessed June 20, 2019.
Mercer. Mercer National Survey. 2019. Available at: www.mercer.com/newsroom/mercer-national-survey-affordability-concerns-lead-more-employers-to-future-focused-strategies-to-manage-health-benefit-cost.html. Accessed June 15, 2019.
Benfield Research Group. Consumer-Directed Health Plans: Pharmacy Benefits and “Better Practices”; 2013. Available at: www.npcnow.org/system/files/research/download/2014npc-benfield-cdhp-better-practices-final.pdf. Accessed June 15, 2019.
Tang KL, Barnieh L, Mann B, et al. A systematic review of value-based insurance design in chronic diseases. Am J Manag Care. 2014;20:e229–e241.
Gibson TB, Wang S, Kelly E, et al. A value-based insurance design program at a large company boosted medication adherence for employees with chronic illnesses. Health Aff (Millwood). 2011;30:109–117.
Choudhry NK, Fischer MA, Avorn J, et al. At Pitney Bowes, value-based insurance design cut copayments and increased drug adherence. Health Aff (Millwood). 2010;29:1995–2001.
Craig P, Cooper C, Gunnell D, et al. Using natural experiments to evaluate population health interventions: new MRC guidance. J Epidemiol Community Health. 2012;66:1182–1186.
Craig P, Katikireddi SV, Leyland A, et al. Natural Experiments: An Overview of Methods, Approaches, and Contributions to Public Health Intervention Research. Annu Rev Public Health. 2017;38:39–56.
D’Agostino RB. Propensity score methods for bias reduction in the comparison of a treatment to a non-randomized control group. Stat Med. 1998;17:2265–2281.
Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011;46:399–424.
US Census Bureau. American Community Survey (ACS). 2019. Available at: www.census.gov/programs-surveys/acs. Accessed February 15, 2019.
Krieger N, Chen JT, Waterman PD, et al. Race/ethnicity, gender, and monitoring socioeconomic gradients in health: a comparison of area-based socioeconomic measures—the public health disparities geocoding project. Am J Public Health. 2003;93:1655–1671.
Fiscella K, Fremont AM. Use of geocoding and surname analysis to estimate race and ethnicity. Health Serv Res. 2006;41(pt 1):1482–1500.
Elliott MN, Fremont A, Morrison PA, et al. A new method for estimating race/ethnicity and associated disparities where administrative records lack self-reported race/ethnicity. Health Serv Res. 2008;43(pt 1):1722–1736.
Ethnic Technologies. Ethnic Technologies Frequently Asked Questions. 2017. Available at: www.ethnictechnologies.com/faq. Accessed June 20, 2019.
Johns Hopkins University. Johns Hopkins ACG® System. 2019. Available at: www.hopkinsacg.org/. Accessed June 15, 2019.
Wharam JF, Zhang F, Landon BE, et al. Low-socioeconomic-status enrollees in high-deductible plans reduced high-severity emergency care. Health Aff (Millwood). 2013;32:1398–1406.
Wharam JF, Zhang F, Wallace J, et al. Vulnerable and less vulnerable women in high-deductible health plans experienced delayed breast cancer care. Health Aff (Millwood). 2019;38:408–415.
Yang D, Dalton JE. A unified approach to measuring the effect size between two groups using SAS®. SAS Global Forum. 2012;6.
Liang K-Y, Zeger SL. Longitudinal data analysis using generalized linear models. Biometrika. 1986;73:13–22.
Zeger SL, Liang KY. Longitudinal data analysis for discrete and continuous outcomes. Biometrics. 1986;42:121–130.
Reid N, Cox D. Analysis of survival data. New York: Chapman and Hall/CRC; 1984. Available at: https://doi.org/10.1201/9781315137438.
doi: 10.1201/9781315137438
Reuters; Robin Respaut, Chad Terhune. U.S. insulin costs per patient nearly doubled from 2012 to 2016, study finds. NBC News. 2019. Available at: www.nbcnews.com/health/diabetes/u-s-insulin-costs-patient-nearly-doubled-2012-2016-study-n961296. Accessed February 15, 2019.
Karter AJ, Parker MM, Solomon MD, et al. Effect of out-of-pocket cost on medication initiation, adherence, and persistence among patients with type 2 diabetes: The Diabetes Study of Northern California (DISTANCE). Health Serv Res. 2018;53:1227–1247.
Cliff BQ, Rozier M, Fendrick AM. Health Insurance Benefits Should Be Equitable, Not Necessarily Equal | Health Affairs. 2017. Available at: www.healthaffairs.org/do/10.1377/hblog20170522.060211/full/. Accessed June 15, 2019.
Karter AJ, Parker MM, Duru OK, et al. Impact of a pharmacy benefit change on new use of mail order pharmacy among diabetes patients: The Diabetes Study of Northern California (DISTANCE). Health Serv Res. 2015;50:537–559.
Lewey J, Gagne JJ, Franklin J, et al. Impact of high deductible health plans on cardiovascular medication adherence and health disparities. Circ Cardiovasc Qual Outcomes. 2018;11:e004632.