The Community Preventive Services Task Force recommends reducing patient out-of-pocket costs (ROPC) for medications to control high blood pressure and high cholesterol when combined with additional interventions aimed at improving patient–provider interaction and patient knowledge, such as team-based care with medication counseling, and patient education

Calonge, Ned

Clymer, John M.

Fielding, Jonathan E.

Glanz, Karen

Goetzel, Ron Z.

Green, Lawrence W.

Johnson, Robert L.

Orleans, C. Tracy

Pronk, Nicolaas P.

Ramirez, Gilbert

Rimer, Barbara K.

PubMed

Carolina Digital Repository

PREVENTING  CHRONIC  DISEASEP U B L I C  H E A L T H  R E S E A R C H ,  P R A C T I C E ,  A N D  P O L I C Y   Volume 12, E209                                                                         NOVEMBER 2015   ESSAY  Recommendation to Reduce Patients’Blood Pressure and Cholesterol MedicationCosts Jonathan E. Fielding, MD, MPH; Barbara K. Rimer, DrPH; Robert L. Johnson, MD;C. Tracy Orleans, PhD; Ned Calonge, MD, MPH; John M. Clymer;Karen Glanz, PhD, MPH; Ron Z. Goetzel, PhD, MA; Lawrence W. Green, DrPH;Gilbert Ramirez, DrPH; Nicolaas P. Pronk, PhD; the Community Preventive ServicesTask Force  Suggested  citation  for  this  article:  Fielding JE,  Rimer BK,Johnson RL,  Orleans CT,  Calonge N,  Clymer JM,  et  al.Recommendation  to  Reduce  Patients’  Blood  Pressure  andCholesterol Medication Costs. Prev Chronic Dis  2015;12:150253.DOI: http://dx.doi.org/10.5888/pcd12.150253.PEER REVIEWEDTask Force FindingThe Community Preventive Services Task Force recommends re-ducing patient out-of-pocket costs (ROPC) for medications to con-trol high blood pressure and high cholesterol when combined withadditional interventions aimed at improving patient–provider in-teraction and patient knowledge, such as team-based care withmedication counseling, and patient education.This recommendation is based on strong evidence of effectivenessin improving medication adherence and outcomes for high bloodpressure and cholesterol. Limited evidence was available to assessthe effectiveness of reducing patient out-of-pocket costs for beha-vioral counseling or behavioral support services independent of re-ducing patient  costs  for  medications.  A summary of  the  TaskForce finding and rationale is at www.thecommunityguide.org/cvd/ROPC.html.DefinitionReducing out-of-pocket costs (ROPC) for patients with high bloodpressure  and  high  cholesterol  involves  program  and  policychanges that make medications for cardiovascular disease (CVD)prevention more affordable. Costs for treatment medications canbe reduced by providing new or expanded treatment coverage andlowering or eliminating patient out-of-pocket expenses (eg, copay-ments, coinsurances, deductibles).Reducing out-of-pocket costs is coordinated through the healthcare system, and preventive services may be delivered in clinicalor nonclinical settings (eg, worksite, community). ROPC can beimplemented alone or in combination with additional interven-tions to enhance patient–provider interaction such as team-basedcare, medication counseling, and patient education. Program andpolicy changes may be communicated to patients and providersusing targeted messages to increase awareness and use of coveredservices.Basis of FindingThe Task Force finding is based on evidence from 18 studies (pub-lished from January 1980 to July 2015) that assessed the effective-ness of reducing out-of-pocket costs for medications to treat highblood pressure, high cholesterol, or both (1). All 18 studies evalu-ated programs or policies that reduced patient out-of-pocket costsfor medications to treat high blood pressure or high cholesterol.Ten studies combined ROPC for medications with one or more ad-ditional interventions including team-based care with medicationcounseling (7 studies), proactive follow-up (5 studies), linkages toother resources and services (4 studies), disease management (3studies), and patient education (4 studies). Nine of 18 studies as-sessed the impact of ROPC for medications on blood pressure andcholesterol outcomes. Six studies assessed the impact of ROPC onadherence to blood pressure- and cholesterol-lowering medica-tions. Only one of 18 studies evaluated the impact of both medica-tion  adherence  and  blood  pressure  and  cholesterol  outcomes.The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Healthand Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.www.cdc.gov/pcd/issues/2015/15_0253.htm • Centers for Disease Control and Prevention      1Twelve studies were policy-based; 7 of these evaluated value-based insurance design (VBID).The Task Force finding reflects 1) the focus of available studies onROPC for  medications,  2)  meaningful  improvements  in bloodpressure and cholesterol outcomes (median decrease of 5.9 and3.75 mm Hg in systolic and diastolic blood pressure, respectively,in 4 studies and a reduction of 15 mg/dL in 1 study) in patientsfrom studies in which most ROPC efforts were combined with ad-ditional interventions such as team-based care with medicationcounseling,  3)  modest  improvements  in  medication adherence(median adherence for all 15 blood pressure and lipid-loweringmedications increased 3.0 percentage points in 6 studies) in stud-ies with ROPC policy changes, and 4) the lack of studies includ-ing or evaluating ROPC for behavioral counseling or behavioralsupport services for patients with high blood pressure or high cho-lesterol, independent of ROPC for medications.ApplicabilityFifteen of the 18 studies were conducted in the United States withstudy populations that included working-age adults balanced bysex.  Studies  examined outcomes in different  racial  and ethnicgroups (ie, Hispanic, white, and African American) with similarresults.  Six studies found effectiveness of ROPC in improvingtreatment outcomes for low-income patients. Overall, results in-dicate that ROPC is effective in a wide range of patients with highblood pressure and high cholesterol in the US health care system.Evidence also shows applicability to diverse policy and programimplementers, such as employers and government agencies.ROPC can be coordinated with other interventions (eg, medica-tion counseling) with the goal of increasing opportunities for pa-tient–provider interaction on treatment issues such as medicationside effects. No harms to patients from these interventions wereidentified in the included studies or the broader literature.Economic EvidenceThe systematic economic review of the intervention included 9studies that evaluated ROPC for medications to treat high bloodpressure or high cholesterol. Seven of these were for reductions inmedication costs as part of VBID plans. Two of the 9 studies com-bined reduced cost for medications with team-based care and 3studies combined reduced medication cost with coaching for life-style or disease management. However, only one of the studies ofthese combined interventions provided the cost to implement boththe ROPC and the added component.Five of the 7 studies that estimated the effect of the intervention onnonpharmacy health care cost indicated these costs were reduced.The time frame of these analyses ranged from 5 years of follow-upto 1 year, with most in the 1- to 2-year range. Three studies thatassessed net benefit of change in health care cost minus interven-tion cost indicated mixed results, one showing the interventionwas cost-neutral and 2 indicating they were cost-increasing. Nostudies reported cost-effectiveness outcomes. An overall econom-ic conclusion about the intervention cannot be drawn from thissmall and inconsistent body of cost-benefit evidence.Considerations for ImplementationThis Task Force finding supports incorporation of policies or pro-grams to reduce or eliminate out-of-pocket costs for medicationsto treat patients with high blood pressure or high cholesterol asone part  of  an effort  to prevent cardiovascular  disease.  Team-based care and disease management programs were common addi-tional interventions evaluated in the reviewed studies; broaderhealth system efforts such as Patient-Centered Medical Homescould also provide a useful infrastructure to coordinate preventionactivities. In addition, partnerships with employers, providers, andcommunity-based organizations may provide resources and set-tings that enhance access to and use of preventive services.Potential implementers include health care providers and plans,government agencies, and self-insured and fully insured employ-ers. Review results suggest opportunities for innovative applica-tion of ROPC policies, coordination of programs, and partner-ships  for  delivery of  services.  Linking medical  and pharmacyclaims data and other information systems across settings may en-hance coordinated service delivery, monitoring of service use, andassessment of program effectiveness for multiple outcomes of in-terest.To increase awareness and use of ROPC covered services, it iscritical to promote ROPC benefits to patients and providers. Only3 of 18 included studies described communicating available bene-fits for reducing out-of-pocket medication costs to patients via let-ter, newsletter, or company intranet. No reviewed studies evalu-ated or reported changes in awareness resulting from activities tocommunicate ROPC benefits.Low-income patients experienced improved blood pressure andcholesterol outcomes after being treated with a combination of in-terventions including ROPC for medications. Implementers shouldconsider promotion strategies that are innovative, culturally appro-priate,  and targeted to  increase  awareness  among low-incomePREVENTING CHRONIC DISEASE VOLUME 12, E209PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY   NOVEMBER 2015The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.2       Centers for Disease Control and Prevention  •  www.cdc.gov/pcd/issues/2015/15_0253.htmgroups  with  low medication  adherence.  Partnering  with  com-munity organizations can also provide opportunities to increaseawareness and use of ROPC benefits among underserved popula-tions.One ROPC policy approach is to reduce or eliminate copaymentsfor generic medications. Providers may need to discuss appropri-ate generic medications with their patients. Prescribing providerscan be important advocates for patients unaware of ROPC bene-fits. Providers can 1) ask patients about their ability to pay formedications and 2) be familiar with medications covered by pa-tients’ health insurance plans and the costs to patients.Reducing out-of-pocket costs for patients with high blood pres-sure and high cholesterol can be implemented as part of a broadereffort to increase use of effective cardiovascular disease prevent-ive services. Evidence in the review, including studies evaluatingVBID, indicates ROPC interventions are effective in increasingadherence to medications in patients with different cardiovascularrisk conditions. A comprehensive approach, for example, couldcoordinate ROPC for medications to improve blood pressure andcholesterol outcomes with evidence-based tobacco cessation treat-ments, coverage to improve management of patients with diabetes,or both. The Affordable Care Act, recognizing the potential ofVBID plans to improve patient receipt of preventive health ser-vices without cost-sharing (2), provides opportunities to reducepatients’ out-of-pocket costs and assist in preventing cardiovascu-lar disease through a section of the law featuring VBID and call-ing for health plan coverage of preventive health services (3).Evidence GapsAlthough evidence indicates effectiveness of ROPC for medica-tions to control high blood pressure and high cholesterol, addition-al research should take into account the assessment of ROPC inother areas of cardiovascular disease preventive services (eg, be-havioral counseling), especially when coordinated with ROPC formedications. Future studies should also describe efforts to effect-ively communicate the presence and availability of covered ROPCbenefits and evaluate both the reach and effectiveness of differentcommunication techniques. Relationships between cost reductionand  patient  use  must  be  examined,  providing  evidence  onthresholds and differential  effectiveness.  In addition,  researchcould examine effectiveness of ROPC by total medication cost,proportional cost-reduction, patient income, or drug patent type.In general, policy studies included in this review examined the im-pact of adding ROPC for medications for an entire patient popula-tion but evaluated only changes in medication adherence. Con-versely, the studies evaluating multicomponent programs that in-clude ROPC for medications examined clinical outcomes for pa-tients in the program but did not report on changes in medicationadherence. Both outcomes provide useful information to potentialimplementers and should be reported together.There are very few complete economic evaluations of ROPC inter-ventions for cardiovascular disease prevention services. Less thanhalf of the interventions evaluated for effectiveness included anyassessment of economic costs or benefits. Cost-effectiveness couldnot be calculated for VBID plans because their evaluations did notreport clinical outcomes such as changes in blood pressure. Thecost of communicating the ROPC benefits to providers and pa-tients was not discussed or estimated in any of the economic stud-ies.Research efforts in these areas can improve understanding of theways in which ROPC for medications to treat high blood pressure,high cholesterol, or both can help improve patient health.AcknowledgmentsThe findings and conclusions in this report are those of the Com-munity Preventive Services Task Force and do not necessarily rep-resent the official position of CDC.No author has any conflict of interest or financial disclosure.Author InformationCorresponding Author: David Hopkins, MD, MPH, CommunityGuide  Branch,  Division  of  Public  Health  InformationDissemination,  Center  for  Surveillance,  Epidemiology,  andLaboratory Services, Centers for Disease Control, 1600 CliftonRd, Mailstop E-69, Atlanta, GA 30329. Telephone: 971-673-1122.E-mail: dhh4@cdc.gov.Author  Affiliations:  Jonathan  E.  Fielding,  University  ofCalifornia, Los Angeles, California; Barbara K. Rimer, Universityof  North  Carolina,  Chapel  Hill,  North  Carolina;  Robert  L.Johnson, Rutgers, The State University of New Jersey, Newark,New Jersey; C. Tracy Orleans, Robert Wood Johnson Foundation,Princeton,  New  Jersey;  Ned  Calonge,  The  Colorado  Trust,Denver, Colorado; John M. Clymer, National Forum for HeartDisease and Stroke Prevention, Washington, DC; Karen Glanz,University of Pennsylvania, Philadelphia, Pennsylvania; Ron Z.Goetzel,  Johns  Hopkins  University,  Baltimore,  Maryland;Lawrence  W.  Green,  University  of  California,  San  Francisco,California;  Gilbert  Ramirez,  Texas  A&M University,  CollegeStation, Texas; Nicolaas P. Pronk, HealthPartners Institute forEducation and Research, Minneapolis, Minnesota.PREVENTING CHRONIC DISEASE VOLUME 12, E209PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY   NOVEMBER 2015The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.www.cdc.gov/pcd/issues/2015/15_0253.htm • Centers for Disease Control and Prevention       3ReferencesNjie GJ, Finnie RKC, Acharya SD, Verughese J, Proia KK,Hopkins  DP,  et  al.  Reducing  medication  costs  to  preventcardiovascular disease: a Community Guide systematic review.Prev Chronic Dis 2015;12:E208.  1.Centers  for  Disease  Control  and  Prevention  (CDC).  Vitalsigns: awareness and treatment of uncontrolled hypertensionamong  adults—United  States,  2003–2010.  MMWR  MorbMortal Wkly Rep 2012;61:703–9.  2.Patient Protection and Affordable Care Act. Public Law 111-148, section 2713(c). 2010. http://www.ncsl.org/documents/health/ppaca-consolidated.pdf. Accessed August 17, 2015.  3.PREVENTING CHRONIC DISEASE VOLUME 12, E209PUBLIC HEALTH RESEARCH, PRACTICE, AND POLICY   NOVEMBER 2015The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services,the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions.4       Centers for Disease Control and Prevention  •  www.cdc.gov/pcd/issues/2015/15_0253.htm

Recommendation to Reduce Patients’ Blood Pressure and Cholesterol Medication Costs

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Recommendation to Reduce Patients’ Blood Pressure and Cholesterol Medication Costs

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