Smith Nicholas K, Fendrick A Mark
Harvard University.
University of Michigan.
J Health Polit Policy Law. 2022 Dec 1;47(6):797-813. doi: 10.1215/03616878-10041191.
Consumer cost sharing is widely employed by payers in the United States in an effort to control spending. Most cost-sharing strategies set patient contributions on the basis of costs incurred by payers and often do not consider medical necessity as a coverage criterion. Available evidence suggests that increases in cost sharing worsen health disparities and adversely affect patient-centered outcomes, particularly among economically vulnerable individuals, people of color, and those with chronic conditions. A key question has been how to better engage consumers while balancing appropriate access to essential services with increasing fiscal pressures. Value-based insurance design (VBID) is a promising approach designed to improve desired clinical and financial outcomes, in which out-of-pocket costs are based on the potential for clinical benefit, taking into consideration the patient's clinical condition. For more than two decades, broad multistakeholder support and multiple federal policy initiatives have led to the implementation of VBID programs that enhance access to vital preventive and chronic disease medications for millions of Americans. A robust evidence base shows that when financial barriers to essential medications are reduced, increased adherence results, leading to improved patient-centered outcomes, reduced health care disparities, and in some (but not most) instances, lower total medical expenditures.
在美国，为了控制开支，支付方广泛采用消费者成本分摊措施。大多数成本分摊策略根据支付方产生的成本来设定患者自付费用，并且通常不将医疗必要性作为承保标准。现有证据表明，成本分摊的增加会加剧健康差距，并对以患者为中心的结果产生不利影响，尤其是在经济上脆弱的人群、有色人种以及患有慢性病的人群中。一个关键问题是，如何在平衡基本服务的适当可及性与日益增加的财政压力的同时，更好地让消费者参与进来。基于价值的保险设计（VBID）是一种有前景的方法，旨在改善预期的临床和财务结果，其中自付费用基于临床获益的可能性，并考虑患者的临床状况。二十多年来，广泛的多利益相关方支持和多项联邦政策举措促使实施了VBID项目，为数百万美国人增加了获得重要预防和慢性病药物的机会。强有力的证据表明，当基本药物的经济障碍减少时，依从性会提高，从而带来以患者为中心的结果改善、医疗保健差距缩小，并且在某些（但不是大多数）情况下，总医疗支出降低。
