Insurance Co-pay Elimination Equals Adherence?

Improving care coordination is a cornerstone of health reform. That's why this is a watershed paper. This is a claim by the Editor-in-Chief David B. Nash. This article describes a strategy known as value-based insurance design (VBID) that supposedly reduces financial barriers to medication access. The major fault I find with the study is that it is from self-reports from the patients. Therefore, I will disagree with the editor and say it is very interesting, but far from a watershed paper.

If, as the study reports, it can improve medication adherence and diabetes management, then this could be more valuable when it is in turn supported by a proper study with more controls. This study compared self-reports from before co-payments were eliminated for diabetes-related medications and supplies. Another self-report one year after reported improved adherence. The statement that there was a significant decrease in out-of-pocket costs associated with non-adherence should be self-evident and therefore not a major surprise.

The lack of specifics about the financial status of the study participants is also a weakness, but maybe that fact that nearly 90% felt elimination of co-payments helped in better self-management indicates a lower financial status. Another weakness is the lack of information about what medications the study participants were taking. Co-payments for insulin and the more expensive oral medications would be a huge factor compared to generic forms of metformin.

The last factor not mentioned in the study is a big one to me. Were the study participants allowed only one test strip per day, or did they have access to “as needed” test strips for more effective blood glucose management. We they given any education about self-monitoring of blood glucose. This could also have created better adherence. Too many pieces of essential information are missing from this study to make the claim the Editor-in-Chief makes. At best, this is something that does need more studies, but also the control of more variables.

This study did raise a great issue and challenge to Medicare and the insurance industry about where viable assistance could play an important role.  Don't expect the insurance industry to rise to this challenge as it could decrease their profits.  Unless, it can be shown in more studies that there is a large future cost savings proved by future studies.  That is the real value of studies like this.