Published Evidence for Value-Based Insurance Design Michael C. Sokol, MD, MS Corporate Medical Director Merck & Co., Inc.

Higher Prescription Co-Pays Associated with Lower Medication Adherence Kessler RC, Cantrell CR, Berglund P, Sokol MC. The effects of co-payments on medication adherence during the first two years of prescription drug treatment. Journal of Occupational and Environmental Medicine. 2007;49(6):

Relationship between Income and Medication Adherence Chernew M, Gibson TB, Yu-Isenberg K, Sokol MC, Rosen AB, Fendrick AM. Effects of Increased Patient Cost Sharing on Socioeconomic Disparities in Health Care. Journal of General Internal Medicine. 2008;23(8):

Employer Example- Service Industry Purpose of study: Examine the impact of lowering Rx co-pays on medication adherence 5 drug classes studied: ACE/ARBs, beta blockers, diabetes medications, statins, inhaled steroids Prospective, pre/post study with control group Time period: 2004 (pre) and 2005 (post) Both intervention and control groups used same disease management programs Chernew ME, Shah M, Wegh A, Rosenberg S, Juster IA, Rosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM. Impact of Prescription Co-payments on Medication Adherence in the Context of a Disease Management Program. Health Affairs. 2008;27(1):

Lower Prescription Co-Pays Associated with Higher Medication Adherence Chernew ME, Shah M, Wegh A, Rosenberg S, Juster IA, Rosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM. Impact of Prescription Co-payments on Medication Adherence in the Context of a Disease Management Program. Health Affairs. 2008;27(1):

Financial Outcomes of Intervention Program led to reduced use of nondrug health care services, offsetting costs associated with additional use of drugs encouraged by the program Thus, the intervention broke even (or even saved money) A targeted intervention, focusing on high-risk patients, would be even more favorable Indirect savings, such as productivity gains, could further offset the additional drug spending Chernew ME, Shah M, Wegh A, Rosenberg S, Juster IA, Rosen AB, Sokol MC, Yu-Isenberg K, Fendrick AM. Evidence that Value-Based Insurance Can Be Effective. Health Affairs. Web Exclusive Jan 2010.

Employer Example- City of Asheville, NC Purpose of study: To assess the persistence of outcomes for up to 5 years following the initiation of community-based pharmaceutical care services for patients with diabetes Education by certified diabetes educators, pharmacist follow-up using scheduled consultations, clinical assessment, goal setting, monitoring, and collaborative drug therapy management with physicians. Diabetes prescription co-pays and diabetic supplies waived for program participation Longitudinal prepost cohort study Time period: Cranor CW, Bunting BA, Christensen DB. The Asheville Project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:

Higher Medication Adherence Associated with Lower Total Health Care Costs Cranor CW, Bunting BA, Christensen DB. The Asheville Project: Long-term clinical and economic outcomes of a community pharmacy diabetes care program. J Am Pharm Assoc. 2003;43:

Employer Example- Large Manufacturer Purpose of study: Examine the impact of medication adherence on hospitalization risk and health care cost 4 disease states studied- diabetes, high blood pressure, high cholesterol, heart failure Retrospective, observational study Time period: Diabetes – 3,260 patients in cohort – Average age was 54 years old – 45% female Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43:

Higher Medication Adherence Associated with Lower Total Health Care Costs Adherence level (% Days supply / 1 year) Average expenditures per patient per year ($) Average expenditures per patient per year ($) P< 0.05 Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43: $8,812$8,812 $6,959 $6,237 $5,887$3,808 $55 $165 $285 $404 $ %20-39%40-59%60-79%80-100% Rx $ Medical $ Diabetes Costs

Higher Medication Adherence Associated with Lower Hospitalization Rate 30* 26* 25* 20* Adherence level (%) Risk (%) Sokol MC, McGuigan KA, Verbrugge RR, Epstein RS. Impact of medication adherence on hospitalization risk and healthcare cost. Medical Care. 2005;43: *Indicates that outcome is significantly higher than outcome for % adherence group (P<0.05). Differences were tested for medical cost and hospitalization risk. Diabetes Hospitalization Risk