Value-based insurance design program in north Carolina increased medication adherence but was not cost neutral.

Value-based insurance design (VBID) has shown promise for improving medication adherence by lowering or eliminating patients' payments for some medications. Yet the business case for VBID remains unclear. VBID is based on the premise that higher medication and administrative expenses incurred by insurers will be offset by lower nonmedication expenditures that result from better disease control. This article examines Blue Cross Blue Shield of North Carolina's VBID program, which began in 2008. The program eliminated copayments for generic medications and reduced copays for brand-name medications. Patient adherence improved 2.7-3.4 percent during the two-year study period. Hospital admissions decreased modestly, but there were no significant changes in emergency department use or total health expenditures. The insurer incurred $6.4 million in higher medication expenditures; total nonmedication expenditures for the study population decreased $5.7 million. Our results provide limited support for the idea that VBID can be cost-neutral in specific subpopulations. The business case for VBID may be more compelling over the long term and in high risk subgroups for whose members cost is an important barrier to improved medication adherence.

Medication adherence changes following value-based insurance design.

OBJECTIVES: To determine whether participation in a value-based insurance design (VBID) program was associated with improved medication adherence in 8 drug classes 2 years after implementation and to examine whether adherence changes varied by baseline adherence. STUDY DESIGN: We used a pre-post quasi-experimental study design with a retrospective cohort of 74,748 enrollees using 8 different therapeutic classes of medications to treat diabetes, hypertension, hyperlipidemia, or congestive heart failure. METHODS: Brand-name medication copayments were lowered (from tier 3 to tier 2) for all enrollees, while generic copayments were waived only for employers who opted into the VBID program. Medication adherence of VBID program participants and nonparticipants 12 months before and 12 and 24 months after program implementation were estimated on 8 propensity-matched cohorts using generalized estimating equations, as well as on subgroups stratified by baseline adherence. Adherence was measured using the medication possession ratio (MPR) from medication refill records. RESULTS: VBID was associated with improved medication adherence ranging from 1.4% to 3.2% at 1 year, which increased to 2.1% to 5.2% 2 years following VBID adoption. Adherence changes were most notable among patients who were nonadherent (MPR <.50) before VBID implementation. CONCLUSIONS: Population-based implementation of VBID can improve adherence to medications to treat cardiometabolic conditions, particularly for previously nonadherent patients. VBID guidelines being developed in response to healthcare reform should account for the heterogeneity in patient response to VBID programs.

Medical costs of secondhand-smoke exposure in North Carolina.

BACKGROUND: The health hazards of exposure to secondhand smoke (SHS) are well-defined. Less is known about the economic costs. We performed an analysis of the medical costs of SHS in North Carolina that was based on a similar study conducted in Minnesota. METHODS: We used 2006 Blue Cross and Blue Shield of North Carolina claims data and national and state surveillance data to calculate the treated prevalence of medical conditions that have been found to be related to exposure to SHS, as established by a 2006 report from the US surgeon general. We used the population attributable risk for these conditions to calculate the number of individuals whose episodes of illness could be attributed to exposure to SHS. We adjusted these treatment costs for other types of insurance provided in the state, using Medical Expenditure Panel Survey data. RESULTS: The total annual cost of treatment for conditions related to SHS exposure in North Carolina was estimated to be $293,304,430, in 2009 inflation-adjusted dollars. Sensitivity analysis showed a range of $208.2 million to $386.3 million. The majority of individuals affected were children, but the greatest costs were for cardiovascular conditions. CONCLUSION: These cost data provide additional rationale for regulating smoking in all work sites and public places.

Copayment reductions generate greater medication adherence in targeted patients.

A large value-based insurance design program offered by Blue Cross Blue Shield of North Carolina eliminated generic medication copayments and reduced copayments for brand-name medications. Our study showed that the program improved adherence to medications for diabetes, hypertension, hyperlipidemia, and congestive heart failure. We found that adherence improved for enrollees, ranging from a gain of 3.8 percentage points for patients with diabetes to 1.5 percentage points for those taking calcium-channel blockers, when compared to others whose employers did not offer a similar program. An examination of longer-term adherence and trends in health care spending is still needed to provide a compelling evidence base for value-based insurance design.

Evaluating the impact of a disease management program for chronic complex conditions at two large northeast health plans using a control group methodology.

The objective of this study was to observe trends in payer expenditures for plan members with one of 14 chronic, complex conditions comparing one group with a disease management program specific to their condition (the intervention group) and the other with no specific disease management program (the control group) for these conditions. The authors used payer claims and membership data to identify members eligible for the program in a 12-month baseline year (October 2001 to September 2002) and a subsequent 12-month program year (October 2002 to September 2003). Two payers were analyzed: one health plan with members primarily in New Jersey (AmeriHealth New Jersey [AHNJ]), where the disease management program was offered, and one affiliated large plan with members primarily in the metro Philadelphia area, where the program was not offered. The claims payment policy for both plans is identical. Intervention and control groups were analyzed for equivalence. The analysis was conducted in both groups over identical time periods. The intervention group showed statistically significant (p < 0.01) differences in total paid claims trend and expenditures when compared to the control group. Intervention group members showed a reduction in expenditures of -8%, while control group members showed an increase of +10% over identical time periods. Subsequent analyses controlling for outliers and product lines served to confirm the overall results. The disease management program is likely responsible for the observed difference between the intervention and control group results. A well-designed, targeted disease management program offered by a motivated, supportive health plan can play an important role in cost improvement strategies for members with complex, chronic conditions.