Xcenda, LLC, Carrollton, TX.
National Pharmaceutical Council, Washington, DC.
J Manag Care Spec Pharm. 2023 Jan;29(1):4-16. doi: 10.18553/jmcp.2022.21270. Epub 2022 Apr 7.
US health plans are adopting benefit designs that shift greater financial burden to patients through higher deductibles, additional copay tiers, and coinsurance. Prior systematic reviews found that higher cost was associated with reductions in both appropriate and inappropriate medications. However, these reviews were conducted prior to contemporary benefit design and medication utilization. To assess the relationship and factors associated with cost-sharing and (1) medication adherence, (2) clinical outcomes, (3) health care resource utilization (HRU), and (4) costs. A systematic review of literature published between January 2010 and August 2020 was conducted to identify the relationship between cost-sharing and medication adherence, clinical outcomes, HRU, and health care costs. Data were extracted using a standardized template and were synthesized by key questions of interest. From 1,995 records screened, 79 articles were included. Most studies, 71 of 79 (90%), reported the relationship between cost-sharing and treatment adherence, persistence and/or discontinuation; 16 (20%) reported data on cost-sharing and HRU or medication initiation, 11 (14%) on costsharing and health care costs, and 6 (8%) on cost-sharing and clinical outcomes. The majority of publications found that, regardless of disease area, increased cost-sharing was associated with worse adherence, persistence, or discontinuation. The aggregate data suggested the greater the magnitude of cost-sharing, the worse the adherence. Among studies examining clinical outcomes, cost-sharing was associated with worse outcomes in 1 study and the remaining 3 found no significant differences. Regarding HRU, higher-cost-sharing trended toward decreased outpatient and increased inpatient utilization. The available evidence suggested higher cost-sharing has an overall neutral to negative impact on total costs. Studies evaluating elimination of copays found either decreased or no impact in total costs. The published literature shows consistent impacts of higher cost sharing on initiation and continuation of medications, and the greater the cost-sharing, the worse the medication adherence. The evidence is limited regarding the impact of cost-sharing on clinical outcomes, HRU, and costs. Limited evidence suggests increased cost-sharing is associated with more inpatient care and less outpatient care; however, a neutral to no difference was suggested for other outcomes. Although increased costsharing is intended to decrease total costs, studies evaluating reducing or eliminating cost-sharing found that total costs did not rise. Today's growing cost-containment environment should carefully consider the broader impact cost-sharing has on treatment adherence, clinical outcomes, resource use, and total costs. It may be that cost-sharing is a blunt, rather than precise, tool to curb health care costs, affecting both necessary and unnecessary health care use. This study and the development of this article were funded by the National Pharmaceutical Council. Mr Sils is an employee of the National Pharmaceutical Council. Dr Graff is a former employee of the National Pharmaceutical Council. Drs Fusco and Kistler and Ms Ruiz are employees of Xcenda. Xcenda received funding to conduct the literature review.
美国医保计划正在通过提高免赔额、增设共付金层级和按比例自付额等方式，将更多的经济负担转嫁给患者。先前的系统性综述发现，较高的费用与适当和不适当药物的使用减少均相关。然而，这些综述是在当代医保计划和药物使用之前进行的。本研究旨在评估成本共付与（1）药物依从性、（2）临床结局、（3）医疗资源利用（HRU）和（4）成本之间的关系和相关因素。我们对 2010 年 1 月至 2020 年 8 月期间发表的文献进行了系统性综述，以确定成本共付与药物依从性、临床结局、HRU 和医疗保健成本之间的关系。使用标准化模板提取数据，并通过感兴趣的关键问题进行综合。从筛选出的 1995 份记录中，有 79 篇文章被纳入。在 79 篇文章中，大多数（71/79，90%）报告了成本共付与治疗依从性、持续时间和/或停药之间的关系；16 篇（20%）报告了成本共付与 HRU 或药物起始、11 篇（14%）报告了成本共付与医疗保健成本以及 6 篇（8%）报告了成本共付与临床结局之间的关系。大多数出版物发现，无论疾病领域如何，增加成本共付均与较差的依从性、持续时间或停药相关。汇总数据表明，成本共付的幅度越大，依从性越差。在研究临床结局的研究中，有 1 项研究表明成本共付与较差的结局相关，其余 3 项研究则未发现显著差异。关于 HRU，较高的成本共付与门诊利用率降低和住院利用率增加有关。现有证据表明，较高的成本共付对总费用有整体中性至负面的影响。评估共付金取消的研究发现，总费用要么减少，要么没有变化。已发表的文献表明，较高的成本共付对药物的起始和持续使用有一致的影响，成本共付的幅度越大，药物的依从性越差。关于成本共付对临床结局、HRU 和成本的影响，证据有限。有限的证据表明，增加成本共付与更多的住院治疗和更少的门诊治疗相关；然而，对于其他结局，研究表明没有差异或中性。尽管增加成本共付旨在降低总费用，但评估减少或取消成本共付的研究发现，总费用并未增加。在当前日益增长的成本控制环境下，应仔细考虑成本共付对治疗依从性、临床结局、资源利用和总费用的更广泛影响。成本共付可能是一种抑制医疗保健成本的粗略而非精确的工具，既影响必要的医疗保健，也影响不必要的医疗保健的使用。本研究和本文的撰写得到了国家药品理事会的资助。Sils 先生是国家药品理事会的员工。Graff 博士曾是国家药品理事会的员工。Fusco 博士、Kistler 博士和 Ruiz 女士是 Xcenda 的员工。Xcenda 获得了进行文献综述的资金。
