How Patients View Pharmacy Benefit Plans and Management Strategies

Sujit S. Sansgiry, PhD; Samir Sikri, MBA

In This Article

Abstract and Introduction

Satisfaction with health plans and plan benefits is important not only to plan beneficiaries but also to health plan providers. A study was conducted in Houston to evaluate patients' satisfaction with their pharmacy benefit plan and to examine the relationship between patient satisfaction and specific drug benefit management strategies. A validated questionnaire was administered to patients (N = 714) who had prescriptions dispensed at any of the 72 community pharmacies that participated in the study to measure satisfaction with pharmacy benefits and attitude toward the use of formularies. Results indicated that, in general, patients were satisfied with their pharmacy benefit plan and with their pharmacists. However, they had a slightly negative attitude toward formularies and did not have adequate knowledge about the use of formularies or the types of drugs covered.

The consumer health services sector is one of the fastest growing and important components of the US economy. In 2002, Americans spent $1.6 trillion on health care, an average of $5440 per person, which represents 14.9% of the gross domestic product (GDP).[1] By 2010, health care spending is expected to increase to $2.6 trillion and account for 15.9% of the GDP, according to a prediction by the Centers for Medicare and Medicaid Services.[2]

Although per capita spending on health care in the United States is more than that of any other developed nation, in many respects, US patients are not the healthiest. In addition, there are no empiric data to indicate that patients are satisfied with the services received from their pharmacy benefit plans.[3] Hence, we designed a study to understand the various factors that contribute to patient satisfaction with pharmacy benefit services provided by health plans.

Historically, health care services have been defined and evaluated from the provider's point of view, with little emphasis on patient satisfaction or input. With the changing economy and a more competitive marketplace, however, more attention is being paid to patients' perception of health care delivery and satisfaction with care.[4] Quality of care provided is now frequently evaluated from the patient's point of view, and satisfaction with health care services is considered an important predictor of quality of care.[4]

Research across various types of businesses reported that, on average, a firm loses as many as 20% of its customers a year because of dissatisfaction with products and services.[5] To gain market share and increase profitability, health plan administrators may find it worthwhile to investigate factors that enhance enrollee satisfaction with their insurance plans.

Studies confirm that patient satisfaction with pharmacy benefit plans is extremely important[6,7,8,9] and may be affected by several factors, such as benefits provided and how patient inquiries are resolved by customer service personnel.[6] In one study, about 70% of respondents viewed the inclusion of a pharmacy benefit as a very important reason for selecting a health insurance plan.[8] In another study, the pharmacy benefit was rated important by 89% of patients, and only about 1% indicated that it was not important.[9] Furthermore, a relationship was reported between satisfaction with the pharmacy benefit and the coverage provided by pharmacy networks, as well as between the former and the out-of-pocket expenditures patients incur for their prescriptions.[10] Another study, which presented results of consumer attitudes toward managed care in general, reported that 45% of consumers were satisfied with their health care plan's prescription drug benefits and about 38% were fairly satisfied.[11]

Information is lacking on any relationship between patient satisfaction and drug benefit management strategies used by health plans, specifically regarding formularies, in conjunction with other components of a well-managed health care system to reduce costs. Other goals for using formularies include promoting high-quality, affordable care; furthering greater standardization of care; fostering the adoption of "best practices" and clinical guidelines; reducing the number of drug interactions; and helping physicians make evidence-based prescribing decisions.[12] Most health plans have incorporated the use of incentivized or tiered formularies, in which a portion of the prescription drug cost is shifted to patients to reduce drug utilization.[13,14]

In incentivized drug benefit designs, each drug is assigned to 1 of 3 or 4 tiers that is tied to a set copayment. The lowest copayments ($10 or less) are for generic drugs. Higher copayments ($15 or more) are for preferred or formulary brand-name drugs, with the highest copayments ($25 or more) reserved for nonpreferred or nonformulary brand-name drugs.[13,14] The proportion of 3-tier incentivized drug benefit designs has increased in recent years from 27% to 63% nationwide.[14] Tiered benefit and copayment designs have been shown to reduce drug use and spending.[15] However, their impact on patient satisfaction has not been sufficiently measured. Another objective of this study was to examine patients' attitudes toward the use of formularies.