Is increasing copayments the best way to manage pharmacy costs? While some plan sponsors may think so, the reality is that higher copayments may lead to patients skipping doses, cutting pills in half, or going without medications. The result might well be lower pharmacy costs, but the long-term impact of noncompliance is high and must be considered before increasing copayment levels.
For example, noncompliance contributes to adverse events, such as readmission to the hospital and unnecessary physician visits, as well as to lower productivity in the workplace. Studies have shown that noncompliance comes at a huge cost to society. Failure to take medications as directed costs the U.S. economy $100 billion per year. Noncompliance is especially prevalent among the elderly and welfare recipients and is of particular concern for patients with chronic diseases such as diabetes and high blood pressure. Adding confusion to this topic are conflicting studies from leading medical journals.
Most clinicians believe that the potential for negatively affecting patient outcomes must be considered when setting copay rates. The emphasis for the benefit must be on the management of pharmacy and medical expenses by means other than solely shifting costs to members.
To ensure the best outcome for patients and to control overall pharmacy and medical costs, plan sponsors should consider broader strategies that go beyond increasing copayments. Some strategies to consider include:
Prior authorization for high utilization and high-cost therapeutic agents to ensure that prescription drugs are prescribed within the guidelines set by the plan, while controlling the misuse of drugs for off-label purposes. It should be noted that the guidelines must be based on nationally accepted standards, supported by clinical outcome studies, and developed by an independent team of practicing physicians, pharmacists, and other clinicians.
Specialty pharmacy programs for expensive injectable medications used for managing chronic conditions. By managing injectables and related services through a comprehensive specialty pharmacy program, costs can be better controlled and distribution, utilization, and case management coordinated to focus on outcomes and return on investment.
Targeted disease interventions to identify patients at risk for noncompliance and provide education and actionable information to providers on their patients who are at risk. This type of disease intervention should also target patients so that they increase their understanding of compliance and the need to talk with physicians about their reasons for not taking medications as prescribed. Education and communication will help physicians and patients make the adjustments necessary to improve compliance.
Polypharmacy programs to avoid duplication of therapy, use of unnecessary therapy, and the use of concomitant medications. This strategy not only controls costs, but is a much better approach for plan members.
Noncompliance should be of particular concern when considering copayment increases because of its potential to increase overall medical costs. Purchasers of health care — be it health plan, employer, or the government — should explore broader strategies to manage the cost of expensive medications, improve patient compliance, and ultimately improve medical outcomes and the quality of life for their members.