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.