Research Roundup: Basing insurance on results, not cost; Americans skeptical of public health efforts; seniors' comprehensive care

The theme for Health Affairs' November issue is "Designing Insurance To Improve Value In Health Care."

Health Affairs: Copayment Reductions Generate Greater Medication Adherence In Targeted Patients - As health care costs have increased, some patients have sought to save money by cutting down on their medications. But "[s]everal employers have reduced or eliminated copayments for selected medications in accordance with value-based insurance design principles. These principles assert that copayment levels should be based on the potential for clinical benefit, not simply on the cost of acquiring those services."

The authors evaluated medication adherence following a January 2008 decision by Blue Cross Blue Shield of North Carolina to change co-payments for "medications to treat diabetes, hypertension, hyperlipidemia (high cholesterol), and congestive heart failure. Copayments for brand-name medications were lowered (from tier 3 to tier 2) for all of the insurer's enrollees, while generic copayments were waived only for employers that opted into the program. ... the elimination of generic copayments and reduction in copayments for brand-name medications improved adherence 2-4 percentage points in the program's first year" (Maciejewski et al., November 2010).

Health Affairs: At Pitney Bowes, Value-Based Insurance Design Cut Copayments And Increased Drug Adherence - In 2007, Pitney Bowes, a large U.S. corporation, eliminated "copayments for statins for its employees and beneficiaries with diabetes or vascular disease and [lowered] copayments for all employees and beneficiaries prescribed the clot-inhibiting drug clopidogrel." Researchers compared Pitney Bowes beneficiaries who received reduced copayments (the intervention cohort) to those "commercially insured beneficiaries of Horizon Blue Cross Blue Shield of New Jersey" (the control group).

The Pitney Bowes beneficiaries' copayments were substantially reduced "(mean monthly statin copayment, $0.60; mean monthly clopidogrel copayment, $8.86)" while the Horizon Blue Cross Blue Shield beneficiaries' copayments "increased slightly for statins ($0.15) and more substantially for clopidogrel ($3.78)," the authors report. The study found "a stabilizing of adherence" in the Pitney Bowes group while the other group declined (Choudhry et al., November 2010).

Health Affairs: Oregon's Test Of Value-Based Insurance Design In Coverage For State Workers - "In 2010, after months of deliberation, two Oregon public employee benefit boards adopted an improved value-based insurance design system" for state workers, according to this analysis. The plans "increase copayments for overused or preference-sensitive services of low relative value, and they cover preventive and high-value services at low or no cost." Business and health care leaders "devised a three-tier value-based design" for coverage. According to the author, so far, "the results have been promising. This article ... illustrates the need to balance optimal policies on coverage and payment with what is politically acceptable to those covered, not only in the state, but also nationwide" (Kapowich, November 2010). 

Health Affairs: Americans' Conflicting Views About The Public Health System, And How To Shore Up Support - This article looks at 12 national opinion surveys, three conducted in 2008, two in 2009, two in 2010, and one in 1940, as well as trend data from 2000, 2002, 2004 and 2006 to explore Americans' views of the public health system.  "This analysis of national opinion polls shows that a majority of Americans support increased spending on public health in general and that they see public health interventions as saving money in the long term. At the same time, many do not favor increased federal spending in a number of areas that public health officials deem important."

"Americans do not believe that the nation's public health system as a whole is working very well. … Respondents also do not see the health of their state's residents as having improved over the past five years. In addition, most do not see state public health departments as having been effective in responding to various chronic disease threats." The authors conclude, "in order to sustain public support for increased spending, it will be critically important to give examples of cost savings from public health programs and to highlight how specific public health programs have reduced mortality from major chronic illnesses, such as cancer, heart disease, and HIV/AIDS" (Blendon, Benson, SteelFisher and Connolly, November 2010).

Journal of the American Medical Association: Comprehensive Primary Care for Older Patients With Multiple Chronic Conditions - This "Clinician's Corner" examines the case of a 77 year old woman who is "typical of the 10 million US residents who are older, living with 4 or more chronic health conditions, and in noninstitutional residences. Their lives (and sometimes their family caregivers' lives) are dominated by disease-related symptoms, disabilities, tests, treatments, and visits to health care clinicians. Their care is very costly, accounting for 80% of the Medicare program's annual expenditures."

"The consensus of experts, based on currently available evidence, indicates that high-quality, cost-effective health care for older patients with multiple chronic conditions is often associated with 4 concurrent, interacting processes that transcend and support the diagnosis and treatment of individual diseases. Unfortunately, mainstream primary care in the United States in 2010 rarely includes these 4 processes ... Based on [a] literature review, 3 comprehensive primary care models appear to have the greatest potential to improve quality of care and quality of life for older patients with complex health care needs, while reducing or at least not increasing the costs of their health care: the GRACE [Geriatric Resources for Assessment and Care of Elders] model, Guided Care, and PACE [Program of All-Inclusive Care of the Elderly]" (Boult and Wieland, 11/3).

New England Journal of Medicine: Using Market-Exclusivity Incentives To Promote Pharmaceutical Innovation - Noting that the "number of new drugs emerging in the U.S. pharmaceutical market is at a low point," this paper reviews "the origins and effects of five important pieces of legislation that support market-exclusivity incentive programs in pharmaceutical research and development. ... Although use of market-exclusivity incentives to promote pharmaceutical innovation has potential benefits, future legislative efforts aimed at encouraging investment in drug research and development should be more precisely designed to avoid waste and misuse, and they should be linked to demonstration of positive public health outcomes," the author writes. "Without these limitations, making exclusivity incentives available to pharmaceutical manufacturers may not be worth the potential risks to public health" (Kesselheim, 11/4).

Health Affairs/Robert Wood Johnson: "Grandfathered" Health Plans - Though grandfathered plans are exempt in the new federal health law "from having to offer the 'essential benefits' package required of other plans as of 2014" and "will also not be subject to the law's limits on out-of-pocket costs for participants," the law creates some regulation prohibiting certain changes to the plan in order to maintain the grandfathered status, according to this policy brief that details the cost-benefit trade-offs for employers and incentives for consumers to remain in grandfathered health plans. (Merlis, 10/29).

Kaiser Family Foundation: Optimizing Medicaid Enrollment: Spotlight On Technology - Wisconsin's ACCESS Internet Portal - This brief "examines how ACCESS, a web-based, self-service tool developed by the state of Wisconsin, helps Wisconsin residents find out whether they may be eligible for BadgerCare Plus and other public programs, as well as apply for benefits, check and renew benefits, and report changes to keep their eligibility current -- all online."

"In November, Wisconsin will release a prototype of the exchange website that the public can try out to see what it will be like to apply for health coverage [in 2014]" (10/28).

Annals of Internal Medicine: Advancing The Science For Active Surveillance: Rationale And Design For The Observational Medical Outcomes Partnership (OMOP) - "Observational databases, containing administrative claims and electronic health records (EHRs), have frequently been used to characterize utilization patterns, track patient outcomes, and conduct formal pharmacoepidemiologic evaluation studies. However, the potential of these observational databases for active surveillance of medical products has not been substantively explored, except for vaccines ... The OMOP, a public-private partnership among the FDA, academia, data owners, and the pharmaceutical industry and administered by the Foundation for the National Institutes of Health ... consists of systematic and empirical investigations of the critical methodological and data resource issues within a specific technology architecture and governance model that is probably needed to establish a national medical product safety surveillance system" (Stang et al., 11/2).