Utilization and Spending With Preventive Drug Lists for Asthma Medications in High-Deductible Health Plans

Abstract

ImportanceHigh-deductible health plans with health savings accounts (HDHP-HSAs) incentivize patients to use less health care, including necessary care. Preventive drug lists (PDLs) exempt high-value medications from the deductible, reducing out-of-pocket cost sharing; the associations of PDLs with health outcomes among patients with asthma is unknown.ObjectiveTo evaluate the associations of a PDL for asthma medications on utilization, adverse outcomes, and patient spending for HDHP-HSA enrollees with asthma.Design, Setting, and ParticipantsThis case-control study used matched groups of patients with asthma before and after an insurance design change using a national commercial health insurance claims data set from 2004-2017. Participants included patients aged 4 to 64 years enrolled for 1 year in an HDHP-HSA without a PDL in which asthma medications were subject to the deductible who then transitioned to an HDHP-HSA with a PDL that included asthma medications; these patients were compared with a matched weighted sample of patients with 2 years of continuous enrollment in an HDHP-HSA without a PDL. Models controlled for patient demographics and asthma severity and were stratified by neighborhood income. Analyses were conducted from October 2020 to June 2023.ExposuresEmployer-mandated addition of a PDL that included asthma medications to an existing HDHP-HSA.Main Outcomes and MeasuresOutcomes of interest were utilization of asthma medications on the PDL (controllers and albuterol), asthma exacerbations (oral steroid bursts and asthma-related emergency department use), and out-of-pocket spending (all and asthma-specific).ResultsA total of 12 174 participants (mean [SD] age, 36.9 [16.9] years; 6848 [56.25%] female) were included in analyses. Compared with no PDL, PDLs were associated with increased rates of 30-day fills per enrollee for any controller medication (change, 0.10 [95% CI, 0.03 to 0.17] fills per enrollee; 12.9% increase) and for combination inhaled corticosteroid long-acting β2-agonist (ICS-LABA) medications (change, 0.06 [95% CI, 0.01 to 0.10] fills per enrollee; 25.4% increase), and increased proportion of days covered with ICS-LABA (6.0% [0.7% to 11.3%] of days; 15.6% increase). Gaining a PDL was associated with decreased out-of-pocket spending on asthma care (change, −$34 [95% CI, −$47 to −$21] per enrollee; 28.4% difference), but there was no significant change in asthma exacerbations and no difference in results by income.Conclusions and RelevanceIn this case-control study, reducing cost-sharing for asthma medications through a PDL was associated with increased adherence to controller medications, notably ICS-LABA medications used by patients with more severe asthma, but was not associated with improved clinical outcomes. These findings suggest that PDLs are a potential strategy to improve access and affordability of asthma care for patients in HDHP-HSAs.

Reduced Cost Sharing and Medication Management Services for COPD

“…These findings from a randomized study of a program that was facilitated by the Value-Based Insurance Design model may help inform the design and evaluation of other programs within the model, which was recently extended by CMS through 2030 . The Value-Based Insurance Design model for prescription drugs has consistently been shown to improve medication adherence and, in some contexts, also improve clinical outcomes and lower total health care spending . More generally, the Value-Based Insurance Design model is intended to improve on traditional cost-sharing mechanisms that have been shown to reduce utilization of both high-value and low-value services …”

Addressing Underinsurance for Children With Special Health Care Needs

“…One policy option is gap coverage targeting medications, akin to a pharmaceutical-focused Medigap plan or Medicare Part D, which would cover specific medications to help lessen the financial burden of costly drugs for CSHCN. Another option is improvement of medication coverage for children enrolled in HDHPs, because parents often forgo medication on HDHP plans, and this can lead to increased hospitalizations for children . These plans could expand coverage of specific pediatric medications, like preventive asthma medications, through expanded drug coverage lists that emphasize prevention of exacerbations of chronic conditions common among CSHCN.…”