Effect of Incentive-Based Formularies on Drug Utilization and Spending
http://www.100md.com
《新英格兰医药杂志》
To the Editor: Huskamp et al. (Dec. 4 issue)1 found that incentive-based formularies affect not only prescription-drug costs, but also patients' compliance with medications. Why do patients use less medication when offered more choice? One possible answer: incentive-based formularies create more complexity than choice.
Three-tiered pharmaceutical benefits are based on the assumption that physicians can serve as agents for their patients and prescribe the least expensive among similarly effective formulary options. But the average physician sees patients who, in total, are covered by more than 13 health plans,2 each offering a unique formulary with individualized incentives. Unfortunately, physicians often inadvertently prescribe medications that require higher out-of-pocket costs for patients, with no marginal clinical benefit, because physicians are not aware of these costs, thus probably contributing to the observed decrease in patients' compliance.
This work calls for research to evaluate physicians' and patients' knowledge of and beliefs about incentives at the time of prescribing. We must also consider approaches to help physicians and their patients navigate complex formularies, especially since recent Medicare legislation endorses an increasing role for private health plans in the provision of prescription drugs.
William H. Shrank, M.D.
Veterans Affairs Greater Los Angeles Health Care System
Los Angeles, CA 90073
shrankw@aol.com
References
Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, Frank RG. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med 2003;349:2224-2232.
Strunk BC, Reschovsky JD. Kinder and gentler: physicians and managed care, 1997-2001. Tracking report no. 5. Washington, D.C.: Center for the Study of Health Systems Change, November 2002. (Accessed February 12, 2004, at http://www.hschange.com/CONTENT/486/?topic=topic03.)
To the Editor: The study by Huskamp et al. demonstrates the need for thoughtful management of both financial incentives and their clinical and economic effects. Ever since the RAND Health Insurance Experiment, it has been known that greater consumer cost sharing can reduce both inappropriate and potentially beneficial care.1 In an era of rising health care costs, the challenge is to reduce the former and maintain (or increase) the latter.
The copayment design of a pharmacy-benefit plan is important in engaging consumers, along with their physicians, in making choices about medications. Other components, however, are critical, including thoughtful tier placement of prescription drugs with use of an evidence-based process, consumer access to effective and easy-to-use decision-support tools, and seamless integration of pharmacy and clinical programs. In UnitedHealthcare's program, we continually assess emerging evidence to place medications in copayment tiers on the basis of total health care value, not just pharmaceutical spending. We also integrate our pharmacy programs with our other clinical initiatives to promote effective, evidence-based care, using data and evidence to assess overuse, underuse, and misuse of pharmaceuticals.
Lewis G. Sandy, M.D.
Timothy Heady, M.B.A., C.P.A.
UnitedHealthcare
Edina, MN 55439
lewis_g_sandy@uhc.com
References
Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med 1981;305:1501-1507.
Three-tiered pharmaceutical benefits are based on the assumption that physicians can serve as agents for their patients and prescribe the least expensive among similarly effective formulary options. But the average physician sees patients who, in total, are covered by more than 13 health plans,2 each offering a unique formulary with individualized incentives. Unfortunately, physicians often inadvertently prescribe medications that require higher out-of-pocket costs for patients, with no marginal clinical benefit, because physicians are not aware of these costs, thus probably contributing to the observed decrease in patients' compliance.
This work calls for research to evaluate physicians' and patients' knowledge of and beliefs about incentives at the time of prescribing. We must also consider approaches to help physicians and their patients navigate complex formularies, especially since recent Medicare legislation endorses an increasing role for private health plans in the provision of prescription drugs.
William H. Shrank, M.D.
Veterans Affairs Greater Los Angeles Health Care System
Los Angeles, CA 90073
shrankw@aol.com
References
Huskamp HA, Deverka PA, Epstein AM, Epstein RS, McGuigan KA, Frank RG. The effect of incentive-based formularies on prescription-drug utilization and spending. N Engl J Med 2003;349:2224-2232.
Strunk BC, Reschovsky JD. Kinder and gentler: physicians and managed care, 1997-2001. Tracking report no. 5. Washington, D.C.: Center for the Study of Health Systems Change, November 2002. (Accessed February 12, 2004, at http://www.hschange.com/CONTENT/486/?topic=topic03.)
To the Editor: The study by Huskamp et al. demonstrates the need for thoughtful management of both financial incentives and their clinical and economic effects. Ever since the RAND Health Insurance Experiment, it has been known that greater consumer cost sharing can reduce both inappropriate and potentially beneficial care.1 In an era of rising health care costs, the challenge is to reduce the former and maintain (or increase) the latter.
The copayment design of a pharmacy-benefit plan is important in engaging consumers, along with their physicians, in making choices about medications. Other components, however, are critical, including thoughtful tier placement of prescription drugs with use of an evidence-based process, consumer access to effective and easy-to-use decision-support tools, and seamless integration of pharmacy and clinical programs. In UnitedHealthcare's program, we continually assess emerging evidence to place medications in copayment tiers on the basis of total health care value, not just pharmaceutical spending. We also integrate our pharmacy programs with our other clinical initiatives to promote effective, evidence-based care, using data and evidence to assess overuse, underuse, and misuse of pharmaceuticals.
Lewis G. Sandy, M.D.
Timothy Heady, M.B.A., C.P.A.
UnitedHealthcare
Edina, MN 55439
lewis_g_sandy@uhc.com
References
Newhouse JP, Manning WG, Morris CN, et al. Some interim results from a controlled trial of cost sharing in health insurance. N Engl J Med 1981;305:1501-1507.