Insurers lower cost-sharing for preventive drugs

Some major health insurers, including Aetna, WellPoint and Humana, have reduced patient cost-sharing for preventive drugs out of a growing realization that lowering cost-sharing increases patient compliance with drug therapies, improving outcomes and cutting the total cost of care.

This is partly the result of the federal healthcare reform law's requirement for first-dollar coverage of recommended preventive services. But it's also related to the growth of consumer-directed health plans with high deductibles. Payers have recognized that covering preventive drugs and other proven medical services below the deductible can make sense from a cost and quality perspective.

Some payers have reduced cost-sharing—including waiving deductibles and reducing or eliminating copayments and coinsurance—for drugs used for primary prevention, such as statins prescribed for patients with high blood cholesterol and lipids who have never had a heart attack. Others such as Aetna have gone further and reduced or waived cost-sharing for drugs used for secondary prevention, such as statins for patients who already have had a heart attack to reduce the chance of a reoccurrence.

Other medications for which some insurers have reduced or waived cost-sharing include drugs for preventing or treating high blood pressure, asthma, stroke, diabetes, osteoporosis, pediatric conditions, and maternal and fetal problems.

There are no data on how many insurers have made these policy changes. But the moves are consistent with the U.S. healthcare system's gradual shift toward a more primary-care and prevention-oriented approach and a greater focus on management of chronic disease.

Aetna launched a value-based health benefits design program called Rx Healthy Outcomes in January. It reduces or waives cost-sharing for certain preventive medications for plan members with certain heart conditions in the hope that better adherence to their drug regimen will lessen the likelihood of a serious event.

“The increase in adherence was enough (to yield) savings in patients not having a subsequent event,” said Dr. Edmund Pezalla, Aetna's national medical director for pharmacy policy and strategy. “Although the cost reduction helped, it's not the whole story.”

Pezalla said Aetna has developed a list of drugs for which copays have been either waived or reduced. He said new drugs and procedures are added based on the findings of the U.S. Preventive Services Task Force as well as a broader review of the medical literature.

He said with most of these medications, Aetna would not “split hairs” and try to determine at what point use of the drug moves from primary to secondary prevention, and that the insurer would base its payment policy on the medication itself, not on the reason people are using it.

WellPoint, the parent company of Anthem Blue Cross and Blue Shield, has adopted a policy that waives or reduces copays for certain preventive medications for chronic conditions such as asthma, diabetes and heart failure, according to company spokeswoman Lori McLaughlin. The company also offers health plan options to large, fully insured and self-insured groups that waive copayments for certain preventive medications.

William Fleming, president of pharmacy solutions for Humana, said lowering cost-sharing for some medications improves compliance. But he argued against eliminating copays completely, saying that only produced incremental improvement compared with reduced cost-sharing. Money, he said, is only one factor in the challenge of patient compliance.

Fleming said Humana offers an education program where nurses counsel patients diagnosed with chronic conditions on the importance of drug adherence, with periodic calls to remind them to keep taking their medications.

Research evidence has been mounting in recent years about the impact of poor drug compliance on healthcare costs. A study by IMS Health released in June estimated that non-adherence to prescribed drug regimens cost the nation about $105 billion in 2012. Nearly 70% of that arose from preventable hospital admissions.

An analysis published last December in the Annals of Internal Medicine found that 20% to 30% of prescriptions are never filled and that up to half of medications are not taken as prescribed. Cost was a large factor for non-adherence, according to the study. It also found that reducing patient out-of-pocket costs for drugs prescribed to prevent heart attacks in patients with diagnosed heart disease decreased the rate of heart attacks by 14%.

“There's been decades of research, which show that when you raise how much patients have to pay, for example if you increase copayments on a medication, that less generous coverage leads to nonadherence,” said Dr. Niteesh Choudhry, an associate professor of medicine at Harvard University.

In a study Choudhry conducted that was published in the New England Journal of Medicine in 2011, he and a research team followed the status of more than 5,000 Aetna members who had recently been hospitalized after suffering a heart attack and were prescribed preventive medications such as statins, beta blockers and ACE inhibitors. Half of the study's participants had to pay the usual copay for their medications while the other half had their copay waived.

The study found the compliance rate among those paying the copay was 38%, compared with 44% for patients who had their copay waived. The rate of hospital readmissions was higher in the copay group than in the group that didn't have to pay the copay.

For the waived copay group, “Because they were healthier, they had to go the doctor less, they had fewer hospitalizations and had fewer emergency room visits,” Choudhry said. “So these other forms of cost-sharing went down. Just in a year of follow-up, (these patients) saved about $500 a person.”

Aetna saved a per-patient average of more than $6,000 in medical costs for the group with the waived copays compared with the copay group, Choudhry said.

Pezalla said the findings in that study were the basis for Aetna to develop its Rx Healthy Outcomes program.

Requiring patients to share some out-of-pocket cost for their medications may help reduce overuse of nonessential drugs, Choudhry said. “But patients have a tough time telling what's really important for them and what's not,” he said.

Improving medication compliance will grow in importance as the country's elderly population increases and more Americans are living with chronic conditions. According to the Centers of Disease Control and Prevention, by 2020, 157 million Americans will have at least one chronic condition such as heart disease, cancer, hypertension, stroke and diabetes.

Katherine Baicker, a professor of health economics at the Harvard School of Public Health, said that as more Americans with lower incomes receive health coverage next year under the Patient Protection and Affordable Care Act, more payers and providers need to better tailor their approaches for improving medication adherence to the individual financial circumstances of patients.

Follow Steven Ross Johnson on Twitter: @MHSjohnson