Association of co-pay elimination with medication adherence and total cost.

OBJECTIVES: To determine whether elimination of co-pays for prescription drugs affects medication adherence and total health care spending. STUDY DESIGN: Retrospective comparative study. METHODS: We conducted a difference-in-differences comparison in the year before and after expansion of a Zero Dollar Co-pay (ZDC) prescription drug benefit in commercially insured Louisiana residents. Blue Cross and Blue Shield of Louisiana members with continuous disease management program enrollment were analyzed, of whom 6463 were enrolled in the ZDC program and 1821 were controls who were ineligible because their employers did not opt in. RESULTS: After ZDC expansion, medication adherence fell in the control group and rose in the ZDC group, with a relative increase of 2.1 percentage points (P = .002). Medical spending fell by $71 per member per month (PMPM) (P = .027) in the ZDC group relative to controls. Overall, there was no significant increase in the cost of drugs between treatment and controls. However, when drugs were further categorized, there was a significant increase of $8 PMPM for generic drugs and no significant difference for brand name drugs. Comparisons of medication adherence rates by household income showed the largest relative increase post ZDC expansion among low-income members. CONCLUSIONS: Elimination of co-pays for drugs indicated to treat chronic illnesses was associated with increases in medication adherence and reductions in overall spending of $63. Benefit designs that eliminate co-pays for patients with chronic illnesses may improve adherence and reduce the total cost of care.

Implicit and Explicit Attitudes Toward Antihypertensive Medications Explain Variation in Pharmacy Refill and Self-Reported Adherence Beyond Traditional Risk Factors: Potential Novel Mechanism Underlying Adherence.

Background In pursuit of novel mechanisms underlying persistent low medication adherence rates, we assessed contributions of implicit and explicit attitudes, beyond traditional risk factors, in explaining variation in objective and subjective antihypertensive medication adherence. Methods and Results Implicit and explicit attitudes were assessed using the difference scores from the computer-based Single Category Implicit Association Test and the Necessity and Concerns subscales of the Beliefs about Medicines Questionnaire, respectively. Antihypertensive medication adherence was measured using pharmacy refill proportion of days covered (PDC: mean PDC, low PDC <0.8) and the self-report 4-item Krousel-Wood Medication Adherence Scale (K-Wood-MAS-4: mean K-Wood-MAS-4, low adherence via K-Wood-MAS-4 ≥1). Hierarchical logistic and linear regression models controlled for traditional risk factors including social determinants of health, explicit, and implicit attitudes in a stepwise fashion. Community-dwelling insured participants (n=85: 44.7% female; 20.0% Black; mean age, 62.3 years; 43.5% low PDC, and 31.8% low adherence via K-Wood-MAS-4) had mean (SD) explicit and implicit attitude scores of 7.188 (5.683) and 0.035 (0.334), respectively. Low PDC was inversely associated with more positive explicit (adjusted odds ratio [aOR], 0.87; 95% CI, 0.78-0.98; P=0.022) and implicit (aOR, 0.12; 95% CI, 0.02-0.80; P=0.029) attitudes, which accounted for an additional 8.6% (P=0.016) and 6.5% (P=0.029) of variation in low PDC, respectively. Lower mean K-Wood-MAS-4 scores (better adherence) were associated only with more positive explicit attitudes (adjusted ß, -0.04; 95% CI, -0.07 to -0.01; P=0.026); explicit attitudes explained an additional 5.6% (P=0.023) of K-Wood-MAS-4 variance. Conclusions Implicit and explicit attitudes explained significantly more variation in medication adherence beyond traditional risk factors, including social determinants of health, and should be explored as potential mechanisms underlying adherence behavior.

Value-based insurance design in Louisiana: Blue Cross Blue Shield's Zero Dollar Co-pay program.

OBJECTIVES: To determine whether a program that eliminated pharmacy co-pays, the Blue Cross Blue Shield of Louisiana (BCBSLA) Zero Dollar Co-pay (ZDC) program, decreased health care spending. Previous studies have found that value-based insurance designs like the ZDC program have little or no impact on total health care spending. ZDC included an expansive set of medications related to 4 chronic diseases rather than a limited set of medications for 1 or 2 chronic diseases. Additionally, ZDC focused on the most at-risk patients. STUDY DESIGN: ZDC began in 2014 and enrolled patients over time based on (1) when a patient answered a call from a nurse care manager and (2) when a patient or their employer changed the benefit structure to meet the program criteria. During 2015 and 2016, 265 patients with at least 1 chronic condition (asthma, diabetes, hypertension, mental illness) enrolled in ZDC. METHODS: Observational study using within-patient variation and variation in patient enrollment month to identify the impact of the ZDC program on health spending measures. We used 100% BCBSLA claims data from January 2015 to June 2018. Monthly level event studies were used to test for differential spending patterns prior to ZDC enrollment. RESULTS: We found that total spending decreased by $205.9 (P = .049) per member per month, or approximately 18%. We saw a decrease in medical spending ($195.0; P = .023) but did not detect a change in pharmacy spending ($7.59; P = .752). We found no evidence of changes in spending patterns prior to ZDC enrollment. CONCLUSIONS: The ZDC program provides evidence that value-based insurance designs that incorporate a comprehensive set of medications and focus on populations with chronic disease can reduce spending.