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Dr Mike Sokol, corporate medical director for Merck and Co., on how value-based benefit design can boost adherence.

Dr Mike Sokol, corporate medical director for Merck and Co., on how value-based benefit design can boost adherence.

Patient compliance with prescribed medication is so poor that Dr Mike Sokol, corporate medical director for Merck and Co., describes non-compliance as an epidemic. World Health Organization data shows that patients fail to take their long-term medication up to 50% of the time, resulting in large numbers of deaths, hospitalizations and emergency department visits, among a range of other public health impacts. The cost may reach $300 billion in the US alone. Employers, who are among the biggest payers in the US healthcare system, pay much of this.

Barriers to adherence include poor communication with patients on the part of clinicians and other healthcare professionals. Lack of knowledge also plays a role; clinicians may not know enough about the patient's circumstances and patients may not know enough about the treatment. Patients attitudes and beliefsinsight into the seriousness of their disease, for example, and their level of trust in their doctorare key factors for adherence. Demographic factors are quite strong indicators of adherence, while social factors such as family support are also important.

Sokol says perceptions about the drugprincipally, side effects, efficacy and costare particularly important to patients, citing research to support that view. One paper, which studied almost 3,000 patients with chronic conditions, found that financial hardship was the most important consideration affecting compliance. According to Sokol, value-based benefit design can help address the cost issue.

Value-based benefit design is underpinned by evidence-based care, Sokol says, and the cost of that care needs to be transparent to patients, who are often unsettled by what they perceive as inequalities. For example, co-payments may differ among patients with similar conditions. Patient involvement is critical, as is promoting value with providers (doctors, nurses, etc), Sokol says, so the design of any healthcare plan needs to have transparency of data. Data should include evidence of effectiveness, all necessary information about the patient and, of course, the cost of the treatment. But do value-based benefit design plans produce better health outcomes and lower costs for payers?

To answer this question, Sokol describes the experience of one large payer, Pitney Bowes, one of the first employers to look seriously at health claims data. Early on, Pitney Bowes provided a wide range of information services to employees to encourage better self-care. This was followed by the launch of a value-based benefit designed health plan. Co-paymentswhich previously had been much higher for branded versus generic drugs, especially for non-preferred drugswere all reduced to a flat rate. After that, there was a substantial improvement in treatment adherence and in adverse outcomes such as hospitalizations. Currently, the cost savings amount to about $5 million.

In a more recent step, Pitney Bowes removed co-payments altogether from the treatments with the strongest evidence of benefit, such as cholesterol-lowering drugs. Sokol describes other data showing that when co-payments are doubled, adherence falls by between 25% and 35%. This is associated with substantial increases in negative clinical outcomes for these patients. Indeed, the levels of co-payment and of adherence are closely and inversely related, as shown by other studies. It is not therefore surprising to see that there is also a close correlation between adherence and income level.

These are retrospective studies, but Sokol also describes a prospective study comparing two companies, one of which had stopped co-payments, in which adherence improved by some 5% in the company that stopped the payments. Another study has shown that removing co-payments for diabetic patients, in return for patients spending time with prescribers and dispensers to learn more about the treatment, results in better clinical outcomes and lower total costs. It appears that co-payment can be separated out as a powerful driver of poor adherence. A study, again including diabetes, found that although removing co-payment increased drug costs, overall costs were lower, in large part due to a 30% fall in diabetic hospitalizations.

Although quite a large amount of evidence comes from studies of diabetes, hyperlipidaemia and cardiovascular disease, there is consistency with other disease areas, too. For example, Sokol cites depression, where it has been shown that better adherence is strongly associated with reduced short-term disability claims. Sokol concludes that a value-based benefit design needs to be simple enough to meet the needs of patients, and that there is very good evidence that both clinical outcomes and costs are significantly improved as a result.