Value-Based Insurance Design Benefit Offsets Reductions In Medication Adherence Associated With Switch To Deductible Plan

Reed ME, Warton M, Kim E, Solomon MD, Karter AJ
Source: Health Affairs
Publication Year: 2017
Patient Need Addressed: Care Coordination/Management, Chronic Conditions
Population Focus: Complex care, Low income, Vulnerable/disadvantaged
Demographic Group: Adult
Study Design: Pre-post without Comparison Group
Type of Literature: White

Enrollment in high-deductible health plans is increasing out-of-pocket spending. But innovative plans that pair deductibles with value-based insurance designs can help preserve low-cost access to high-value treatments for patients by aligning coverage with clinical value. Among adults in high-deductible health plans who were prescribed medications for chronic conditions, we examined what impact a value-based pharmacy benefit that offered free chronic disease medications had on medication adherence. Overall, we found that the value-based plan offset reductions in medication adherence associated with switching to a deductible plan. The value-based plan appeared particularly beneficial for patients who started with low levels of medication adherence. Patients with additional clinical complexity or vulnerable populations living in neighborhoods with lower socioeconomic status, however, did not show adherence improvements and might not be taking advantage of value-based insurance design provisions. Additional efforts may be needed to educate patients about their nuanced benefit plans to help overcome initial confusion about these complex plans.

Insights Results

Overview of article

  • This study examined the impact on patient medication adherence of introducing a value-based pharmacy benefit that offered free chronic condition medications

Methods of article

  • To study the impact of the pharmacy benefit, the authors used a quasi-experimental difference-in-differences study design to compare changes in medication adherence as patients switched from a nondeductible plan in 2013 to a deductible-based plan in 2014, with plans paired with either a value-based pharmacy benefit or no value-based pharmacy benefit
  • The authors identified all integrated delivery system members in Kaiser Permanente of North California’s system, whose employers changed from a non-deductible copayment based traditional health maintenance organization plan to a high-deductible plan
  • The primary study outcome was adherence to the chronic condition medications on the value-based insurance design (VBID) medications list


  • The study found that patients with the value-based pharmacy benefit maintained comparable levels of adherence after switching to a deductible plan compared with statistically significantly greater decreases in adherence in patients who switched to a deductible plan with no value-based pharmacy benefit. The VBID group had 2.1% differentially higher adherence than the no-VBID group when switching to a deductible-based plan
  • Patients with lower baseline adherence had statistically significantly improved adherence under the VBID benefit. Surprisingly, patients with lower neighborhood socioeconomic status or a higher medication burden did not show adherence improvements even with free medications, compared to enrollees who paid the full cost for these medications (there was a 1.8% decrease in adherence in the VBID group and a 2.4% decrease in the non-VBID group)

Key takeaways/implications

  • This is the first study to report that VBID impacts differ specifically among patients living in lower-socioeconomic status neighborhoods or patients with more complex medication regimens
  • VBID provisions are a potential tool to use in offsetting financial barriers from deductibles and can help maintain low-cost access to high-value healthcare services and treatments
  • The surprising fact that patients living in neighborhoods with lower socioeconomic status didn’t show any significant adherence improvement VBID benefit may be explained by the inverse care law, meaning patients living in neighborhoods with lower socioeconomic status might face additional barriers to medication adherence (e.g., lower health engagement, lower health literacy)
  • Moving forward, policy makers and purchasers who implement a VBID benefit might need to make additional efforts to educate patients about their nuanced benefit plan to overcome initial confusion about these complex plans
  • Limitations to the study include conducting the study in a single integrated delivery system with extensive chronic condition management programs that are offered regardless of pharmacy benefit type, use of an averaged contextual measure that might not represent any individual patient’s education or income, inability to identify what other insurance options employees might have had and how these might have compared with the benefit plans in this study, and potential confounding factors