The Noncompliance Epidemic

Can We Get Patients to Be More Compliant?

Neil Chesanow


January 16, 2014

In This Article

Picking Up the Tab for Patients' Drugs

The innocuous-sounding term "cost-sharing" -- charging patients ever-steeper copays for their medications -- was one business strategy that seriously backfired for health insurers when it came to patient compliance.

A study by the RAND Corporation, a research organization, found that doubling copays reduced compliance by 25%-45%.[16] As patients' use of medication declined, emergency room visits increased 17% and hospital admissions rose 10% among patients with diabetes, asthma, or gastric disorder.[16]

Other studies, particularly of cardiac patients, reached the same conclusion: The money saved by, in effect, incentivizing patients to use fewer drugs vaporized -- and then some -- when the resulting increase in ER and hospital visits was factored in.[4,17]

This realization sparked a complete about-face in strategy: "value-based insurance design" (VBID).[18,19,20] In VBID, certain patients, particularly those with certain chronic conditions, are given their drugs for free or at reduced cost, in the hope that removing cost barriers to compliance will keep them on regimen and out of the ER and the hospital, both of which cost a good deal more.

One much-discussed study, published in 2011, put this theory to the test.[4] It compared 2845 Aetna health plan members discharged from the hospital after an episode of acute myocardial infarction, who received all their drugs -- statins, beta-blockers, angiotensin-converting enzyme (ACE) inhibitors, or angiotensin receptor blockers (ARBs) -- for free, vs 3020 Aetna enrollees who had the usual prescription coverage. Rates of compliance were only 36%-49% in the usual-coverage group. But without the cost barrier, rates were only 4%-6% higher.

Still, researchers and industry analysts consider even this modest boost in outcomes, typical of the small incremental gains achieved by noncompliance interventions (assuming they achieve anything at all), to be encouraging.

Aetna, which funded this research, also has programs that eliminate or reduce copays for drugs for asthma and diabetes. Other insurers offer VBID initiatives for patients with potentially costly chronic conditions as well.

"We'll probably expand our program to other disease states," predicts internist Edmund Pezalla, MD, MPH, Aetna's National Medical Director of Pharmacy Policy & Strategy. "These are blanket programs. They go into effect when someone's been on a medication for a little while."

"Ultimately other programs will supplant these first-generation value-based designs," he says. Eventually, insurers will simply offer inexpensive generic drugs across the board as the most cost-effective solution.


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