University of Washington, Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, Box 357630, H375 Health Science Building, Seattle, WA, 98195-7630, USA.
Kaiser Permanente Washington Health Research Institute, 1730 Minor Ave, Suite 1600, Seattle, WA, 98101-1466, USA.
Pharmacoeconomics. 2019 Oct;37(10):1287-1300. doi: 10.1007/s40273-019-00821-5.
It is unclear whether private insurance benefit designs align with the most widely used ex-US definition of value, the incremental cost-effectiveness ratio (ICER). A large Pacific Northwest private insurance plan explicitly implemented a tiered formulary based on cost-effectiveness estimates of individual drugs in 2010, resulting in cost savings to the plan without negatively affecting patient health service utilization. Given the pressures of rising costs, we investigate whether employer-based private health insurance plans have adopted value-based cost-sharing approaches that are in line with cost-effectiveness estimates.
At the drug level, we identified five drug tier designations (0-4) that are tied to increasing ICER ranges in a large claims dataset from 2010 to 2013. We used a random effects model to evaluate whether out-of-pocket (OOP) cost levels and trends were associated with drug value designation, controlling for generic status and list price, and whether the associations varied by insurance plan type and insurance market concentration, as measured by the Herfindahl-Hirschman Index (HHI). We also estimated the weighted mean cost effectiveness of the drug claims in the sample by year and generic status using the formulary's cost-effectiveness value ranges.
The 2010 volume weighted mean OOP cost for a 30-day supply of drugs in tiers 0 through 4 were $US6.87, $US22.62, $US62.22, $US57.36, and $US59.85, respectively (2013 US dollars). OOP costs for cost-saving and preventive drugs (tier 0) decreased 5% annually from 2010 to 2013 (p < 0.01); OOP costs for drugs costing under $US10,000/quality-adjusted life-year (QALY) (tier 1) decreased 4.5% annually (p < 0.01) and OOP costs for drugs costing over $US50,000/QALY (tier 3) and $US150,000/QALY (tier 4) decreased by 2.4% and 2.2%, respectively (p < 0.01 and p = 0.046). OOP costs for drugs valued between $US10,000 and $US50,000/QALY did not change significantly (p = 0.31). Average ICER estimates increased for generic drugs and did not change for brand name drugs.
OOP costs for prescription drugs are decreasing across value levels, with OOP costs for higher-value drugs generally decreasing at a faster rate than lower-value drugs. The relationship between cost sharing and value remains tenuous, however, particularly at higher ICER levels, likely reflecting the persistence of traditional formulary structures and increasing use of generic drugs over brand name drugs.
目前尚不清楚私人保险福利设计是否符合美国以外最广泛使用的价值定义，即增量成本效益比（ICER）。2010 年，太平洋西北地区的一项大型私人保险计划明确根据个别药物的成本效益估算实施了分级处方，这为计划节省了成本，同时又没有对患者的医疗服务利用产生负面影响。鉴于成本上升的压力，我们调查了雇主为基础的私人医疗保险计划是否采用了符合成本效益估算的基于价值的成本分担方法。
在药物层面，我们在 2010 年至 2013 年的大型索赔数据集中确定了五个药物分层指定（0-4），这些分层指定与不断增加的 ICER 范围有关。我们使用随机效应模型来评估自付（OOP）成本水平和趋势是否与药物价值指定相关，同时控制了通用状态和标价，并根据赫芬达尔-赫希曼指数（HHI）来评估保险计划类型和保险市场集中程度对关联的影响。我们还根据处方的成本效益价值范围，估算了样本中药物索赔的加权平均成本效益。
2010 年，30 天供应量的药物在 0 到 4 层的 OOP 成本分别为 6.87 美元、22.62 美元、62.22 美元、57.36 美元和 59.85 美元（2013 年美元）。2010 年至 2013 年，节省成本和预防药物（0 层）的 OOP 成本每年下降 5%（p<0.01）；成本低于 10000 美元/QALY（1 层）的药物 OOP 成本每年下降 4.5%（p<0.01），成本超过 50000 美元/QALY（3 层）和 150000 美元/QALY（4 层）的药物 OOP 成本分别下降 2.4%和 2.2%（p<0.01 和 p=0.046）。成本在 10000 美元至 50000 美元/QALY 之间的药物 OOP 成本没有显著变化（p=0.31）。通用药物的平均 ICER 估算值增加，而品牌药物的 ICER 估算值没有变化。
处方药的自付费用在各个价值水平上都在下降，高价值药物的自付费用通常比低价值药物下降得更快。然而，成本分担和价值之间的关系仍然很脆弱，特别是在更高的 ICER 水平上，这可能反映了传统处方结构的持续存在以及通用药物相对于品牌药物的使用增加。
