Deductible Plan with Free Chronic Disease Medications Mary Reed, - - PowerPoint PPT Presentation

Value-Based Insurance Designs: Medication Adherence after Switching to a Deductible Plan with Free Chronic Disease Medications

Mary Reed, DrPH

Division of Research Kaiser Permanente Northern California AcademyHealth Annual Research Meeting June 2016

Kaiser Permanente Research

Study Team

Mary Reed, DrPH1

• E. Margaret Warton, MPH1

Eileen Kim, MD2 Matthew Solomon, MD, PhD1,2 Andrew Karter, PhD1

1Kaiser Permanente Division of Research 2The Permanente Medical Group, Northern California

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Research funded by: Health Policy and Disparities Grant No Conflicts of Interest to Declare

Kaiser Permanente Research

Background

• US health insurance enrollees are increasingly facing

health plan deductibles with high out-of-pocket costs

• Higher out-of-pocket medication costs are associated

with greater cost-related medication underuse

• Patients with lower socio-economic status (SES) have

reported more cost-based reductions in medication adherence

• Combining value-based insurance designs (VBID) with a

high-deductible plan can limit out-of-pocket costs for high value services

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Research Questions

Among patients switching to a plan with a deductible, how does having a VBID pharmacy benefit (free chronic disease medications) impact:

• Overall patient medication adherence?
• Adherence in patient groups?

– Lower baseline medication adherence – Lower SES – Higher medication burden

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Study Setting and Benefit Plans

• Integrated Health Care Delivery System (IDS): Kaiser Permanente

Northern California (KPNC)

• Health plan deductibles apply to care until spending reaches the

deductible:

Medical services (office visits, ED visits, etc.) and most medications VBID eligible medications: Diabetes, hypertension, lipid control, asthma, etc.

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Fixed Copayment Full Cost Free ($0) Free ($0)

Spending Reaches Deductible Amount

Study Design

• Design: Difference-in-differences 2013-2014
• Population:
• Adult: age 18-64
• Employer-sponsored insurance plan
• Switch from no deductible to deductible plan (in 2014)
• Taking a VBID-eligible medication at baseline

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Study Group 2013 Plan Switch 2014 VBID No Deductible Deductible + VBID No VBID No Deductible Deductible

Measures and Analysis

• Exposure: Switch into a VBID pharmacy plan linked to a deductible plan (vs. no

VBID)

• Outcomes: Medication adherence among VBID-eligible medications

– Medications for diabetes (oral medications), lipid control, or hypertension – Proportion of days covered (PDC) – percent time with adequate medication

• Analysis: Random effects linear regression with interaction between time period

and VBID exposure

– Covariates:

• Patient age, sex, race/ethnicity, language preference, complex chronic conditions, and

medical center

– Stratified analysis:

• Baseline adherence (<80%)
• Neighborhood SES
• Medication burden (count, $)

– Sensitivity analyses

• Deductible $1000+
• Adherence outcome defined as 80%+ (logistic regression)

– Percentages based on population-level estimates

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Table 1: Baseline Patient Characteristics: VBID and Non-VBID Groups

Characteristics Total (N=2,482) VBID (N=1,458) No VBID (N=1,024) p-value % % % Female 45.9 48.4 42.4 0.003 Age (yr): 18-44 18.4 16.9 20.6 0.018 45-64 81.6 83.1 79.4 Race: Black 12.6 11.5 14.2 <0.0001 White 44.5 43.1 46.5 Asian 19.3 22.8 14.3 Hispanic 15.2 13.8 17.2 Other 8.5 8.9 7.9 English Speaker 96.1 93.8 99.4 <0.0001 Lower SES 19.2 21.8 15.4 <0.0001 Chronic Conditions: Diabetes 23.8 23.7 23.9 0.91 Coronary Artery Disease 4.0 3.8 4.3 0.57 Heart Failure 1.7 1.9 1.3 0.21 Hypertension 57.5 58.0 56.9 0.61 Count of Chronic Conditions: 0 28.4 28.0 28.6 0.69 1 52.7 53.4 51.7 2 16.6 16.5 16.9 ≥3 2.5 2.2 2.8

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Lower SES = patient lives in a census block group with ≥25% of adult residents earning less than a high school education or ≥20% of households with annual income below the federal poverty line

Figure 1. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan

76.1 73.8 74.3 74.1 70 72 74 76 78 No Deductible (2013) Deductible (2014) Adherence (%) No VBID VBID VBID Differential: 2.1% (0.4,3.9)

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Figure 2. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan by baseline adherence

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93.4 89.7 93.1 89.3 50.7 50.3 48.8 53.6

40 50 60 70 80 90 100 No Deductible (2013) Deductible (2014) Adherence (%)

No VBID (Adherent) VBID (Adherent) No VBID (Non-Adherent) VBID (Non-Adherent)

Non Adherent Patients: VBID Differential 5.2% (1.8, 9.6)

Adherent Patients: VBID Differential

• 0.1% (NS)

Non-adherent: N=1024 (41.2%)

Figure 3. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan by SES

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71.4 69.4 72 70.2 77 74.6 75.2 75.4

68 70 72 74 76 78 No Deductible (2013) Deductible (2014) Adherence (%)

No VBID (Lower SES) VBID (Lower SES) No VBID (Higher SES) VBID (Higher SES) Lower SES: VBID Differential 0.2% (NS)

Higher SES: VBID Differential 2.5% (0.6, 4.5)

Lower SES N=476 (19.2%)

Figure 4. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan by medication burden

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75.2 72 73.2 72.8 80.2 83.2 83.6 84.2

68 72 76 80 84 No Deductible (2013) Deductible (2014) Adherence (%)

No VBID (Low <5) VBID (Low <5) No VBID (High 5+) VBID (High 5+) High (5+): VBID Differential

• 2.9% (NS)

Low (<5): VBID Differential 2.8% (0.8, 4.8)

High medication burden (5+ VBID medications): N=339 (13.7%)

Limitations

• Single delivery system
• Non-experimental allocation of benefit plans
• High baseline medication adherence
• Widespread low-cost generic medication use
• Adherence measures based on pharmacy data

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Conclusions

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• Medication adherence remained steady when switching

to a deductible plan with a VBID pharmacy plan

• Compared to declines in adherence after switching to a non-

VBID deductible plan

• Patients with lower adherence improved their adherence

with a VBID pharmacy plan, even when switching to a deductible for other services

• Patients with higher SES or taking fewer medications

improved their adherence under the VBID pharmacy plan

• No improvements in adherence for patients with lower SES or

greater medication burden

Implications

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• VBID plans can offset reductions in medication

adherence associated with switching to a deductible plan

• VBID pharmacy plans can be particularly beneficial in

patients with low medication adherence

• Patients with additional clinical complexity or vulnerable

populations with lower SES may need additional engagement or education about VBID provisions

Thanks!

Mary Reed mary.e.reed@kp.org

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Extras

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Table 1: Baseline Patient Characteristics: VBID Exposed and Unexposed Groups (2013)

Characteristics Total VBID No VBID p-value N=2,482 % N=1,458 % N=1,024 % Female 1,140 45.9 706 48.4 434 42.4 0.003 Age (yr) 18-44 457 18.4 246 16.9 211 20.6 0.018 45-64 2,025 81.6 1,212 83.1 813 79.4 Race Black 313 12.6 168 11.5 145 14.2 <0.0001 White 1,104 44.5 628 43.1 476 46.5 Asian 478 19.3 332 22.8 146 14.3 Hispanic 377 15.2 201 13.8 176 17.2 Other 210 8.5 129 8.9 81 7.9 English Speaker 2,385 96.1 1,367 93.8 1,018 99.4 <0.0001 Low SES 476 19.2 318 21.8 158 15.4 <0.0001 Chronic Conditions Diabetes 591 23.8 346 23.7 245 23.9 0.91 Coronary Artery Disease 100 4.0 56 3.8 44 4.3 0.57 Heart Failure 41 1.7 28 1.9 13 1.3 0.21 Hypertension 1,428 57.5 845 58.0 583 56.9 0.61 Count of Chronic Conditions 701 28.4 408 28.0 293 28.6 0.69 1 1,307 52.7 778 53.4 529 51.7 2 413 16.6 240 16.5 173 16.9 ≥3 61 2.5 32 2.2 29 2.8

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Table 2. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan*

21 Group No VBID VBID Differential change in medication adherence* VBID vs No VBID No VBID VBID No Deductible Deductible No Deductible Deductible N (%) N (%) Adherence (%) p-value Adherence (%) Adherence (%) Adherence (%) Adherence (%) By Adherence* Adherent 862 (59.1) 596 (40.9)

• 0.14

0.876 93.4 89.7 93.1 89.3 Non-Adherent 596 (58.2) 428 (41.8) 5.22 0.003 50.7 50.3 48.8 53.6 By Socioeconomic Status1 Low SES 318 (66.8) 158 (33.2) 0.17 0.941 71.4 69.4 72.0 70.2 Not Low SES 1140 (56.8) 866 (43.2) 2.52 0.011 77.0 74.6 75.2 75.4 By Medication Burden2 Low (<5) 1275 (59.3) 868 (40.5) 2.82 0.006 75.2 72.0 73.2 72.8 High (5+) 183 (54.0) 156 (46.0)

• 2.89

0.059 80.2 83.2 83.6 84.2

Difference-in-difference in adherence for chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) calculated using full cohort with treatment/post values set to identify each of the 4 comparison groups. Models adjusted for age, sex, race/ethnicity, low SES census tract, English speaker, comorbidity count at end of 2012, and medical center. *Adherence to chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) defined as proportion of days covered with adequate medication (%); Non- adherent defined as <80%

1 Based on patient residential address. Positive values indicate better outcomes in VBID group vs No VBID group. 2 Number of different chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) filled during 2013

Figure 1. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan

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76.1 73.8 74.3 74.1 70 72 74 76 78 80 No Deductible (2013) Deductible (2014) Adherence (%) No VBID VBID

Figure 1. Percent change in medication adherence after switching to deductible plan with and without VBID pharmacy plan

76.1% 74.3% 73.8% 74.1%

72 73 74 75 76 77 No VBID VBID Adherence (%)

No Deductible (2013) Deductible (2014)

2.3% 0.2%

No Deductible (2013) Deductible (2014)

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Figure 3. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan* by SES

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71.4 69.4 72 70.2 77 74.6 75.2 75.4

68 70 72 74 76 78 No Deductible (2013) Deductible (2014) Adherence (%)

No VBID (Low SES) VBID (Low SES) No VBID (Not Low SES) VBID (Not Low SES) VBID Differential (Low SES): 0.17 VBID Differential (Not Low SES): 2.52

Table 2. Differential change in medication adherence after switching to deductible plan with and without VBID pharmacy plan*

25 Group No VBID VBID Differential change in medication adherence* VBID vs No VBID No VBID VBID No Deductible Deductible No Deductible Deductible N (%) N (%) Adherence (%) p-value Adherence (%) Adherence (%) Adherence (%) Adherence (%) All Patients 1458 (58.7) 1,024 (41.3) 2.13 0.019 76.1 73.8 74.3 74.1 By Patient Subgroup (pre-deductible) Adherence* Adherent 862 (59.1) 596 (40.9)

• 0.14

0.876 93.4 89.7 93.1 89.3 Non-Adherent 596 (58.2) 428 (41.8) 5.22 0.003 50.7 50.3 48.8 53.6 Socioeconomic Status1 Low SES 318 (66.8) 158 (33.2) 0.17 0.941 71.4 69.4 72.0 70.2 Not Low SES 1140 (56.8) 866 (43.2) 2.52 0.011 77.0 74.6 75.2 75.4 Medication Burden2 Low (<5) 1275 (59.3) 868 (40.5) 2.82 0.006 75.2 72.0 73.2 72.8 High (5+) 183 (54.0) 156 (46.0)

• 2.89

0.059 80.2 83.2 83.6 84.2

Difference-in-difference in adherence for chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) calculated using full cohort with treatment/post values set to identify each of the 4 comparison groups. Models adjusted for age, sex, race/ethnicity, low SES census tract, English speaker, comorbidity count at end of 2012, and medical center. *Adherence to chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) defined as proportion of days covered with adequate medication (%); Non- adherent defined as <80%

1 Based on patient residential address. Positive values indicate better outcomes in VBID group vs No VBID group. 2 Number of different chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) filled during 2013

Table A1. Differential change in low medication adherence (PDC<80%) after switching to deductible plan with and without VBID pharmacy plan*

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Group Low medication adherence* VBID vs No VBID Odds Ratio (OR) p-value All Patients 0.81 0.30 Stratified by Socioeconomic Status1 Low SES 0.91 0.853 Not Low SES 0.80 0.306 Stratified by Medication burden2 Low (<5) 1.95 0.224 High (5+) 0.71 0.115

*Low adherence to chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) defined as less than 80% proportion of days covered (PDC) with adequate medication

1 Based on patient residential address. Positive values indicate better outcomes in VBID group vs

No VBID group.

2 Number of different chronic conditions medications covered by the VBID plan (Diabetes, lipid

control, hypertension) filled during 2013

Table 3. Sensitivity analyses by medication burden: Differential change in low medication adherence after switching to deductible plan with and without VBID pharmacy plan*

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Group Differential Change in Medication Adherence* VBID vs No VBID No VBID VBID No Deductible Deductible No Deductible Deductible Adherence (%) p-value Adherence (%) Adherence (%) Adherence (%) Adherence (%) VBID Medication Out-of-Pocket Cost1 Low (<$130) 3.30 <0.001 72.0 68.5 71.8 71.6 High (>$130)

• 0.27

0.835 84.8 85.2 88.6 88.7 By Medication Burden (VBID-eligible medications)2 Low (<5) 2.82 0.006 75.2 72.0 73.2 72.8 High (5+)

• 2.89

0.059 80.2 83.2 83.6 84.2 Medication Burden (all medications)2 Low (<9) 3.43 0.002 74.8 71.8 72.6 73.0 High (9+)

• 1.25

0.424 78.6 78.3 79.5 78.0

*Adherence to chronic conditions medications covered by the VBID plan (Diabetes, lipid control, hypertension) defined as proportion of days covered with adequate medication (%)

1 Total out-of-pocket costs paid by patient for VBID-covered medications during 2013. 2 Total number of prescriptions for different medications filled during 2013

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