Varying Pharmacy Benefits with Clinical Status

The Case of Cholesterol-Lowering Therapy

Published in: American Journal of Managed Care, v. 12, no. 1, Jan. 2006, p. 21-28

Posted on on January 01, 2006

by Dana P. Goldman, Geoffrey F. Joyce, Pinar Karaca-Mandic

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OBJECTIVE: To determine whether a pharmacy benefit that varies copayments for cholesterol-lowering (CL) therapy according to expected therapeutic benefit would improve compliance and reduce use of other services. METHODS: Using claims data from 88 health plans, we studied 62 274 patients aged 20 years and older who initiated CL therapy between 1997 and 2001. We examined the association between copayments and compliance in the year after initiation of therapy, and the association between compliance and subsequent hospital and emergency department (ED) use for up to 4 years after initiation. RESULTS: The fraction of fully compliant patients fell by 6 to 10 percentage points when copayments increased from $10 to $20, depending on patient risk (P < .05). Full compliance was associated with 357 fewer hospitalizations annually per 1000 high-risk patients (P < .01) and 168 fewer ED visits (P < .01) compared with patients not in full compliance. For patients at low risk, full compliance was associated with 42 fewer hospitalizations (P = .02) and 21 fewer ED visits (P = .22). Using these results, we simulated a policy that eliminated copayments for high- and medium-risk patients but raised them (from $10 to $22) for low-risk patients. Based on a national sample of 6.3 million adults on CL therapy, this policy would avert 79 837 hospitalizations and 31 411 ED admissions annually. CONCLUSION: Although many obstacles exist, varying copayments for CL therapy by therapeutic need would reduce hospitalizations and ED use--with total savings of more than $1 billion annually.

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